Carlin Prom Registration

NICKLAUS CHILDREN'S PATIENTS ARE INVITED TO BRING A GUEST WITH THEM TO THE PROM. PARENTS (UP TO 2 FAMILY MEMBERS) ARE INVITED TO ATTEND THE PARENT RECEPTION. PLEASE REGISTER FOR BOTH EVENTS USING THE FORM BELOW.

PATIENT PROM: Hall of Ambassadors (1^st Floor)
PARENT RECEPTION: Venetian Room (1^st Floor)
HAIR/MAKE UP: Cordoba and Almeria (2^nd Floor)

Patient Information

Patient First Name*:

Patient Last Name*:

Date of Birth (MM/DD/YYYY)*:

Phone Number*:

( ) -

Email*:

Address*:

City*:

State*:

U.S. ZIP code*:

Dress Or Suit Size*:

Favorite Color*:

Shoe Size*:

Will you be bringing a guest?*:

Will your parent/guardian(s) be attending?*:

Guest Name:

Guest Phone Number:

( ) -

Parent/Guardian Name*:

Parent/Guardian Phone Number*:

( ) -

Parent/Guardian Name:

Parent/Guardian Phone Number:

Patient Needs

Please provide a list of all diagnoses*:

List of all known allergies, dietary restrictions and activity restrictions*:

List any medical equipment (ex: ventilator, oxygen) the patient will be utilizing during the event (from 6:00 pm to 10:00 pm)*:

Hold Harmless Agreement

Hold Harmless Agreement: I have read and agree to the content stated in the Event Release/Waiver/Hold Harmless Agreement.

I Agree*

Emergency Medical Treatment Agreement

Emergency Medical Treatment Form: The parents or guardians of patient understand that our son/daughter, may require immediate medical attention during the Carlin Family Nicklaus Children’s Prom, and that every measure will be taken to contact us should there be a need for medical treatment; however, should an immediate need arise, my child will be transported to the Nicklaus Children’s Hospital Emergency Department for treatment. A Consent for Treatment will be required at the time of registration.

I Agree*

Media Release Form

Media Release Form: By submitting this form, I hereby give my consent and authorization to Nicklaus Children’s Health System, Nicklaus Children’s Hospital, and Nicklaus Children’s Hospital Foundation, including its physicians, authorized technicians, employees, and authorized agents (collectively “NCHS”) to photograph, film, create digital images, video, interview, create sound recordings, or otherwise create media content (“Content”) of me child related to the Nicklaus Children’s Hospital Carlin Family Prom. I understand that such media content may include my face, image, likeness, voice, name and age.

I Agree*

Choose one option for Dress or Suit Appointment:

Choose one option for hair and make-up appointment:

The agreements and releases of consent presented above have been electronically signed by a parent, legal guardian or patient over 18 years of age:

E-Signature (type your name)*:

Carlin Prom Registration

Patient Information

Patient Needs

Hold Harmless Agreement

Emergency Medical Treatment Agreement

Media Release Form

Get Involved

Events

Impact

About Us

Ways To Give