Casey Cares Foundation New Program Application

Child’s Name:

p First Middle Last

Nickname:

Birthdate: / / Age: Male □ Female □ T-shirt size: Month/Date/Year

Home Address: Street Apt#

City, State Zip Code County

Home Phone: Area Code Number

Cell Phone: Please check: Father □ Mother □ Other □ Area Code Number

Cell Phone: Please check: Father □ Mother □ Other □ Area Code Number

Email: Please check: Father □ Mother □ Other □ Alternate Email: Please check: Father □ Mother □ Other □ (We do many of our communication through email so it is important that we have your email address) Parent 1: Relationship to patient:

Parent 2: Relationship to patient:

Legal Guardians: (other than parents) (If child resides with one parent and the other parent is living, please attach a copy of the custody order or both parents must sign all documents)

Siblings under 22 living at home: Name Birthdate (date/month/year) Relationship

How did you hear about the Casey Cares Foundation? Does your child require wheelchair assistance? Social Worker/Child Life Worker’s name: Please complete all areas and sign both the

Application and Permits. OVER

Office Use Only

New Update

v 2.16

Child’s name:

Name of Child’s Primary Physician: Name of Hospital or Clinic: Address: Telephone: ( )

Child’s Medical Diagnosis:

Your employment information: Employer’s name Please check: Father □ Mother □ Employer’s address I understand that the participation of any person in Casey Cares Foundation Programs is contingent upon approval of the Casey Cares Foundation. I also will abide by all conditions of the Liability and Publicity Permit. I state that the information provided by me is true. Parent/Guardian Date Parent/Guardian Date Witness Date

Please forward Page 3 to your child’s physician and social worker. The application may be faxed to our office, however, we request that you mail the original as soon as

possible to the Casey Cares Foundation office.

www.CaseyCaresFoundation.org

Child’s name:

Tell us about your child (please check appropriate boxes and be as specific as possible)

What sports does your child like: What kind of music does your child enjoy:

□ Baseball □ Soccer □ Basketball □ Country □ R&B □ Pop □ Rock □ Rap

□ Football □ Ice Hockey □ Lacrosse □ Easy Listening □ World □ Jazz

□ WWE □ Cheerleading □ Other __________ □ Other ____________

Preferred venue for a family event:

□ Verizon Center □ Norfolk Scope □ Izod Center

□ 1st Mariner Arena □ Prudential Center □ Patriot Center

□ Giant Center (Hershey) □ Richmond Coliseum □ Wells Fargo Center (Philly)

□ Sun National Bank Center (Trenton) □ Mohegan Sun Arena (Wilkes-Barre)

□ Other: ___________________________________________

What movie theater is convenient for you family :

□ AMC Theaters □ Regal Theaters □ R/C Theater □ Other □ We don’t go to the mvoies

Favorite restaurants:__________________________________________________________________________ _________________________________________________________________________________________ Favorite characters from books, movies, or TV:____________________________________________________ _________________________________________________________________________________________ Name some of you child’s favorite celebrities:_________________________________________________ ____ _____________________________________________________________________________________ ___ What are your child’s favorite hobbies:___________________________________________________________ ________________________________________________________________________________________ What are your child’s favorite colors:____________________________________________________________ Tell us what activities your child likes to do as a family (watching movies, going to the zoo, ect..): _________________________________________________________________________________________ Other things you would like to tell us about your child: ______________________________________________

__________________________________________________________________________________

PHYSICIAN’S DOCUMENTATION This medical evaluation is being completed and signed by PLEASE PRINT

Hospital : City/State Phone #: Fax #: e-mail: Child’s illness: Critical □ Chronic □ Is child frequently hospitalized? Yes □ No □ Is child on active treatment? Yes □ No □ Restrictions with participation in programs Initial date of diagnosis: Last treatment date: Date of last office visit: I am the primary physician for this child. The Parent(s)/Guardians(s) have full knowledge of child’s illness and are aware of how to handle medical emergencies. If Parent(s)/Guardians(s) adhere to physician’s recommendations and instructions, there is no medical contraindication to patient’s participation in Casey Cares Programs and patient will not present medical risks to others. Physician’s signature Date

SOCIAL WORKER/CHILD LIFE WORKER INFORMATION Name: Phone: Fax: Beeper: Area Code Number

e-mail address: Additional information about family: Please let us know if you need additional information about Casey Cares guidelines or programs Social Worker/Child Life Worker’s Signature Date

Application may be faxed to our office, however, we request that you mail the original as soon as possible.

Child’s name:

When completed, please forward to: Casey Cares Foundation 3918 Vero Rd., Suite C Baltimore, MD 21227 Phone: 443-568-0064

Fax: 443-524-9949