Hope@Home Weekend Application

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Hope@Home™ Weekend Application

Our mission is to inspire hope in young families, with children 18 or under, facing the loss of a parent to a life-threatening illness.

Does this match your family's situation?

Yes No

Please select an answer*

Thank you for your interest in applying for Inheritance of Hope. Our mission is to inspire hope in young families, with children 18 or under, facing the loss of a parent to a life-threatening illness. Since you do not meet those specific requirements we are unable to serve you through our family events. Please feel free to check out our website and Hope@Home™ app for some resources that might be helpful to you.

Diagnosed Parent Info:

First Name* Required*

Last Name* Required*

Birth Date* Required*

T-Shirt Size* Required*

Mobile Number* Required*

Email Address* Required*

Diagnosis* Required*

Stage/Grade Required*

Mailing Address* Required*

City* Required*

State* Required*

Zip* Required*

Spouse/Caregiver Info:

Name Required*

Birth Date Required*

Relationship to Applicant Required*

Mobile Number Required*

Email Address Required*

T-Shirt Size Required*

Children Info:

Child 1:

Name* Required*

Birth Date* Required*

Relationship to Applicant* Required*

T-Shirt Size* Required*

Any Special Needs?

Child 2:

Name Required*

Birth Date Required*

Relationship to Applicant Required*

T-Shirt Size Required*

Any Special Needs? Required*

Child 3:

Name Required*

Birth Date Required*

Relationship to Applicant Required*

T-Shirt Size Required*

Any Special Needs? Required*

Child 4:

Name Required*

Birth Date Required*

Relationship to Applicant Required*

T-Shirt Size Required*

Any Special Needs? Required*

Child 5:

Name Required*

Birth Date Required*

Relationship to Applicant Required*

T-Shirt Size Required*

Any Special Needs? Required*

Child 6:

Name Required*

Birth Date Required*

Relationship to Applicant Required*

T-Shirt Size Required*

Any Special Needs? Required*

If you have more than 6 children, please enter their info below. Required*

Contact Info:

We will be working on a special surprise for your family and we need some help! We would love it if you could list at least three contacts who know your family well and understand your unique situation (i.e. a close relative, neighbor, school counselor/teacher, coach, pastor, co-worker, club representative, etc.).
Please provide the following information for each contact:

1st Contact info:

Name* Required*

Relationship to Applicant* Required*

Mobile Number* Required*

Email Address* Required*

2nd Contact info:

Name* Required*

Relationship to Applicant* Required*

Mobile Number* Required*

Email Address* Required*

3rd Contact info:

Name* Required*

Relationship to Applicant* Required*

Mobile Number* Required*

Email Address* Required*

Additional Contact info:

(Name, Relationship, Phone Number, Email Address) Required*

Agreement:

Informed Consent Agreement
(Click to Read)

A) I understand, recognize, and agree that Inheritance of Hope employs a variety of facilitators in order to provide a quality experience to all Participants. I understand that I can request information regarding my facilitators' education and experience backgrounds from Inheritance of Hope.

B) I understand, recognize, and agree that a safe group environment is created and maintained by both the facilitators and the group members offering mutual respect and trust. Confidentiality is also primary for a safe group environment. Group facilitators are bound by law to maintain confidentiality. Participants are bound by honor to maintain confidentiality. Should I desire to share what I learn in group, I agree to do so without using group members' names or in any way compromising group members' confidentiality. I acknowledge that there are legal and professional limits to confidentiality. I understand that I can request more information about these limits from Inheritance of Hope.

C) I understand, recognize, and agree that my children and/or teenagers will have age-appropriate group experiences for healthy emotional processing. The above elements also apply to children and teenager groups. I understand that children and teenagers will not focus on specific details of any parent's illness but will address the fact that all have an ill parent in common.

D) I understand and agree to all terms of event group participation. I also understand and agree that any Participant can contact Inheritance of Hope for more information about any aspect of the group experience.

You must agree to the term. *

Release Agreement
(Click to Read)

A) I understand that participation in an Inheritance of Hope event is purely voluntary.

B) On behalf of myself and all the Participants listed on this form, their heirs, personal representatives, guardians, successors, and assigns, I hereby unconditionally, irrevocably, and absolutely release, discharge, and agree to indemnify and hold harmless Inheritance of Hope, its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries, from any and all loss, liability, claims, demands, causes of action, costs or expenses (including attorneys’ fees), damages or suits of any type, whether in law and/or in equity, related directly or indirectly, or in any way connected with the Participants’ participation in the Inheritance of Hope event.

C) I understand, recognize, and agree that there are dangers, hazards, and risks associated with participation in the event. I understand that participation in the event may result in injury, property damage, interaction with persons having potentially communicable diseases, and/or death. I acknowledge that I understand and have fully considered the dangers, hazards, and risks associated with the event and voluntarily assume the risks associated with participation in the event. I hereby unconditionally, irrevocably, and absolutely release, discharge, and agree to indemnify and hold harmless Inheritance of Hope, its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries, from any and all loss, liability, claims, demands, causes of action, costs or expenses (including attorneys’ fees), damages or suits of any type, whether in law and/or in equity, in the event of injury, property damage, disease, and/or death related directly or indirectly, or in any way connected with the Participants’ participation in the Inheritance of Hope event.

D) I understand, recognize, and agree that I am fully responsible for my child(ren) throughout the event.

E) By my/our signature(s) set forth below, I/we authorize Inheritance of Hope to photograph, film, and/or electronically record interviews with me/us in such a manner as they choose. I further give permission and consent that any such photographs, films, and/or electronically recorded interviews may be published and used by Inheritance of Hope and its agents to illustrate and promote the event experience and Inheritance of Hope.

F) By my signature set forth below, I the Applicant understand that I am unconditionally, irrevocably, and absolutely authorizing Inheritance of Hope to share the medical information contained in this application with its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries.

G) I agree that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of South Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Any claims against Inheritance of Hope arising from or related to this Agreement or the event must be submitted to binding arbitration in accordance with the applicable rules of the American Arbitration Association. Any arbitration shall be sited in Oconee County, South Carolina.

You must agree to the term. *

SMS Opt-In*

By providing your/your family's phone number(s), you agree to receive text messages from Inheritance of Hope.
Message & data rates may apply. Message frequency varies.
Reply STOP to opt out, reply HELP for help

You must choose an option*

Opt-in

I/we hereby warrant that I/we have read the foregoing Agreements and executed them freely and voluntarily.

I/we consent to providing my/our legally effective electronic signature(s) by typing full legal name(s) below and entering today's date.

I/we authorize Inheritance of Hope to photograph and/or film to promote the event experience on social media and/or other marketing materials.

You must agree to the term. *

Please indicate below which event works for your family: You must select the date. *

February 9-11, 2024 These dates don’t work, please put me on a waiting list.

Diagnosed Parent's Signature

Signature* Required Field *

Signature Date* Required Field *

Spouse/Caregiver's Signature

Signature Required Field. *

Signature Date Required Field *

Parent/Guardian's Signature

Signature* Required Field *

Signature Date* Required Field *

How did you hear about Inheritance of Hope? Required Field *

For trouble filling out the form, please email:
Tech@InheritanceOfHope.Org

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