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. 

English – For more information contact Samantha Selvin at 786.719.8054 or samantha.selvin@nicklaushealth.org
Spanish – Para mas informacion por favor contactar a Carmen Hidalgo at 305.342.2320 or carmen.hidalgo@nicklaushealth.org

Patient Information

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Patient Needs

Mask Wearing and Covid-19 Testing

Masking Acknowledgment: By submitting this form, I consent to wearing a face mask at all times on-site while at the event.
COVID-19 Consent: By submitting this form, I consent to doing COVID-19 Testing prior to attending event and providing results to Nicklaus Children’s Hospital Foundation.

Hold Harmless Agreement

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

Emergency Medical Treatment Agreement

Emergency Medical Treatment Form: Parents are welcome to stay on the even premises in a designated parent reception area while your child attends the event. Should your child require scheduled medication and/or medical intervention (i.e. suction, aerosol, etc.), we require that you bring any and all required medication and any medical supplies for your administration in a designated area which will be made available to you and your child.

We, the parents or guardians understand that our son/daughter, may require immediate medical attention during the Carlin Family Nicklaus Children’s Hospital 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.

Media Release Form

Media Consent: 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.
Westland Mall Location Only
Westland Mall Location Only

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