*Please allow for 15 minutes to complete this form.

Eligibility Requirements

• Programs are for critically ill children under the age of 18 and their immediate family members only.
• Patients must be diagnosed with a life-threatening illness, be receiving active treatment, and be frequently hospitalized.
• The child's primary physician and social worker should complete applications. When more than one diagnosis is involved, each attending physician must complete a medical statement.
• Eligibility will be determined by the Foundation after physician's assessment.
• Applications will be reviewed and approved by Program Director.
• Applications for critically ill children will be updated and reviewed every two years. Siblings may participate in programs until age 21.
• Patients will remain eligible for one year after last active treatment (Routine follow-ups excluded).
• Families are encouraged to participate in programs through the Better Together Program for one year after the loss of the child participating in programs.
• Patients must live in MD, PA, DE, NJ, VA, WV or DC to participate in Casey Cares Programs

Child's Information
Child's' Name:	*
Child's Birthdate	*	/ /
Child's Gender	*	Male Female
Child's T-Shirt Size
Child's Photo
Does you child require wheelchair assistance	*	Yes No
Home Address
Street Address:	*
City:	*
State:	*	Zip:   Patients must live in MD, PA, DE, NJ, VA, WV or DC to participate in Casey Cares Programs
E-mail Address:	*
Home Phone:	*
Mother's Cell Phone:	*
Father's Cell Phone:	*
Parents
I am the child's:	*	Mother Father
Mother's Name:	*
Father's Name:	*
Legal Guardians:		(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)
How did you hear about Casey Cares?:
Your Employment Information
Employer:	*
Employer Address:	*
Siblings
Sibling:
Sibling:
Sibling:
Sibling:
Medical Information
Child's Primary Physician:	*
Hospital/Clinic:	*
Street Address:
City:
State:		Zip:
Phone:	*
Child's Diagnosis:	*
Physician's Evaluation:		Download the Physician's Documention form to be completed and mailed/faxed by your physician to the address/number provided on the form.
Social Worker/Child Life Worker Information
Social Worker/Life Worker Name:
Social Worker/Child Life Worker Documentation:		Download the Social Worker/Life Worker Documention form to be completed and mailed/faxed by your physician to the address/number provided on the form.
Tell Us About Your Child
What sports does your child like:	*	Baseball Soccer Basketball Football Ice Hockey Lacrosse Other:
What music does your child like:	*	Country R&B Pop Rock Rap Easy Listening World Jazz Other:
Favorite restaurants:	*
Favorite characters from books, movies or TV:	*
Favorite Celebrities:	*
Favorite Hobbies:	*
Favorite Colors:	*
Favorite Activies as a Family: (going to the zoo, etc)	*
Other things you would like to tell us about your child:
Other Information
Additional Comments:
Terms and Conditions
Liability Permit:	*	The undersigned agrees to the following: 1. The undersigned has requested participation in Casey Cares Foundation Programs. All Participants agree to forever release and absolve Casey Cares Foundation for, from and against any and all liability, damages and claims of any kind, known and unknown which may be connected with or result from participation in Casey Cares Foundation Programs. 2. Participants understand and agree that involvement in Casey Cares Foundation Programs may involve injury or harm to the Participants and agree that this risk is fully assumed by the Participants. This includes, but not limited to problems connected with transportation, lodging, food, all medical conditions, publicity to include photographs, accidental injury, death or harm to the Participants and that all risk is fully assumed by all Participants. Participants agree to carry full medical coverage or assume personal responsibility for failing to carry adequate medical insurance. The Participants hold Casey Cares Foundation harmless for any loss as the result of any claim, lawsuit or action arising out of or relating to the preparation, execution or fulfillment of the benefit conferred upon the Participants. 3. The undersigned both individually and on behalf ofthe child who is eligible to participate in Casey Cares Foundation Programs does release and absolve Casey Cares Foundation, their volunteers, employees, directors and agents and all other persons, businesses and corporations which may be liable from any and all actions, causes of action, claims and demands for, any damage for any incidents or occurrence which occur during the participation or consideration of participation in Casey Cares Foundation Programs. 4. The parent(s) or legal guardian(s) gives permission to Casey Cares Foundation to contact the physician and/or medical personnel familiar with the child's medical diagnosis. This will determine the child's eligibility in Casey Cares Foundation Programs. All physicians and/or medical personnel have permission to release my child's medical information to the Casey Cares Foundation. The parents or legal guardians have made true and full disclosure of the medical condition and all additional information to Casey Cares Foundation. The parents or legal guardians understand that the Casey Cares Foundation may disclose their child's information to any third party involved in program participation. 5. It is further understood that this permit contains the entire agreement between the Participants and Casey Cares Foundation. All participants involved agree to the terms in this permit. This agreement expresses the understanding of all participants in Casey Cares Programs. By signing, you agree and acknowledge that you have fully read and understand this agreement. I have read the terms and agree.
Publicity Permit:	*	The undersigned agrees to the following: I. It is understood and agreed that participation in Casey Cares Foundation Programs may result in publicity. By signing this permit you are allowing Casey Cares Foundation to use the name, photos or video of all Participants, for publicity purposes. 2. Casey Cares Foundation is very aware of the desire for privacy and will respect any reasonable requests from program Participants. However, the media or general public may acquire information concerning the Participants and any event; thus publicity may result. Each Participant must understand that information regarding Casey Cares Programs may be publicized and the Participants release Casey Cares Foundation from all liability. Each of the Participants hereby releases Casey Cares Foundation from all damages, liability or claims resulting from, or arising from the use, distribution or disclosure of any photographs, films, newsletters, videotapes, websites, press releases or other information regarding Participants. 3. I agree that all Participants have read and understand this Publicity Permit for Casey Cares Foundation programs prior to signing it. The undersigned authorize and hereby bind themselves, their minor children, and all participants, their heirs, successors and estates to the conditions in this release. Each Participant agrees that this permit is accurate and expresses the understanding of each and every Participant. Each of the Participants agrees that no modification of this release has been made orally or in writing and this release accurately and fully expresses the understanding of all Participants 4. By signing below, you agree and acknowledge that you have read and fully understand this agreement. All Participants involved agree to all terms in this permit. The agreement expresses the understanding of all Participants in Casey Cares Foundation Programs. 6. It is further understood that this release contains the entire agreement between the Participants and Casey Cares Foundation concerning publicity. All Participants involved agree to the terms in this release. This agreement expresses the understanding of all participants in Casey Cares Programs. By signing, you agree and acknowledge that you have fully read and understand this agreement. By signing this permit, you are allowing Casey Cares Foundation to use the name, photos or video of all Participants for publicity purposes. I have read the terms and agree.