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Age of Child Attending *

Name of Child (First & Last Name) *

List any additional children attending and their ages:

Does the child have any known allergies? *

Yes
No

If yes, please specify:

Name of Attending Adult (First and Last) *

Attending Adult Phone *

Street Address *

City *

State/Province/Region *

Zip Code *

How many adults will be attending the event? *

Emergency Contact Phone *

Briefly describe the nature of your child's loss: *

How recent was the death? (e.g., within the past month, over a year, etc.) *

How did you hear about this event? *

THBR Staff
THBR Website
Social Media
Marketing Event
Word of Mouth
Other

VIDEO/PHOTOGRAPH RELEASE: I hereby grant The Hospice of Baton Rouge the irrevocable right and permission to use photographs and/or video recordings of me at events such as Camp Conquer, Family Day, or other events and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me. I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of The Hospice of Baton Rouge. I hereby release, acquit and forever discharge the State of Louisiana, The Hospice of Baton Rouge, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation. I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives. *

Yes
No

Signature (First and Last Name) *

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