Hope Hub™
Registration

Hope Hub™ welcomes families facing the loss, or who have already experienced the loss, of a parent due to a life-threatening illness.

Does this match your family's situation?

Yes

Thank you for your interest in Inheritance of Hope.
We exist to serve families who have a parent with a terminal illness.
Thankfully that is not you and we hope and pray that it never is!
For other ways to be connected to Inheritance of Hope visit our
“Connect” webpage.

Required*

Please tell us more about you... Required*

Comments

Fill out the questions below.

Select a Hope Hub™ location.* Required*

8905 Ox Road, Lorton, VA 22079

Location to be determined.
8901 France Ave. S. Bloomington, MN 55431

1435 Atlantic Blvd, Jacksonville, FL 32207

Location to be determined.

Coming Soon!

Is the diagnosis life-threatening?* Required*

Yes

Do you have children 18 years old or younger?* Required*

Yes

Inheritance of Hope exists to serve families who have children ages 18 and under.
If your children are slightly above that age and you think they could still be a good fit for our program then
please continue with the application >>
Otherwise, please visit our “Connect” webpage for other ways to be connected to Inheritance of Hope.

Do you have a spouse or a caregiver?* Required*

Yes

Diagnosed Parent Info:

First Name* Required*

Last Name* Required*

E-Mail* Required*

Mobile* Required*

Birthdate* Required*

Gender Required*

T-Shirt* Required*

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Spouse/Caregiver Registration:

First Name Required*

Last Name Required*

E-Mail Required*

Mobile Required*

Birthdate Required*

Gender Required*

T-Shirt Required*

Same address as Diagnosed Parent Required*

Yes

Street Address Required*

City Required*

State Required*

Zip Required*

Child Registration:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

T-Shirt* Required*

Special Needs for the Child

Informed Consent Agreement*

You must agree to the term*

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.

Release Agreement*

You must agree to the term*

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.

SMS Opt-In*

You must agree to the term*

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

Opt-in

Consent Electronic Signature*

You must agree to the term*

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 agree

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

Signature:

Signature* Required*

Signature Date* Required*

Comments

Fill out the questions below.

Select a Hope Hub™ location.* Required*

8905 Ox Road, Lorton, VA 22079

Location to be determined.
8901 France Ave. S. Bloomington, MN 55431

1435 Atlantic Blvd, Jacksonville, FL 32207

Location to be determined.

What is your relationship to the diagnosed parent?* Required*

Is the diagnosed parent still alive?* Required*

Yes

Is the diagnosis life-threatening?* Required*

Yes

Did/does the diagnosed parent have children 18 years old or younger?* Required*

Yes

Diagnosed Parent Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Date of Death* Required*

E-Mail* Required*

Mobile* Required*

Gender Required*

T-Shirt* Required*

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Spouse/Caregiver Registration:

First Name Required*

Last Name Required*

E-Mail Required*

Mobile Required*

Birthdate Required*

Gender Required*

T-Shirt Required*

Same address as Diagnosed Parent Required*

Yes

Street Address Required*

City Required*

State Required*

Zip Required*

Child Registration:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Gender Required*

T-Shirt* Required*

Special Needs for the Child

Informed Consent Agreement*

You must agree to the term*

Release Agreement*

You must agree to the term*

SMS Opt-In*

You must agree to the term*

Opt-in

Consent Electronic Signature*

You must agree to the term*

I agree

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

Signature:

Signature* Required*

Signature Date* Required*

Parent/Guardian Signature:

If you are under 18 years old, you must get your parent/guardian signature.

Signature*

Signature Date*

Comments

Fill out the questions below.

Select a Hope Hub™ location.* Required*

8905 Ox Road, Lorton, VA 22079

Location to be determined.
8901 France Ave. S. Bloomington, MN 55431

1435 Atlantic Blvd, Jacksonville, FL 32207

Location to be determined.

Is the diagnosed parent still alive?* Required*

Yes

Is the diagnosis life-threatening?* Required*

Yes

Are\were you the caregiver or is\was someone else?* Required*

I am the caregiver.

Someone else is the caregiver.

What is their relationship to the diagnosed parent?* Required*

What is your relationship to the diagnosed parent?* Required*

Diagnosed Parent Info:

First Name* Required*

Last Name* Required*

Birthdate* Required*

Date of Death* Required*

E-Mail* Required*

Mobile* Required*

Gender Required*

T-Shirt* Required*

Street Address* Required*

City* Required*

State* Required*

Zip* Required*

Caregiver Registration:

First Name Required*

Last Name Required*

E-Mail Required*

Mobile Required*

Birthdate Required*

Gender Required*

T-Shirt Required*

Same address as Diagnosed Parent Required*

Yes

Street Address Required*

City Required*

State Required*

Zip Required*

Child Registration:

First Name Required*

Last Name Required*

Birthdate Required*

Gender Required*

T-Shirt Required*

Special Needs for the Child

Informed Consent Agreement*

You must agree to the term*

Release Agreement*

You must agree to the term*

SMS Opt-In*

You must agree to the term*

Opt-in

Consent Electronic Signature*

You must agree to the term*

I agree

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

Signature:

Signature* Required*

Signature Date* Required*

Parent/Guardian Signature:

If you are under 18 years old, you must get your parent/guardian signature.

Signature*

Signature Date*

If you have any technical issues with this form,
please email Tech@InheritanceOfHope.Org

Hope Hub™
Registration

Fill out the questions below.

Diagnosed Parent Info:

Spouse/Caregiver Registration:

Child Registration:

Informed Consent Agreement*

Release Agreement*

SMS Opt-In*

Consent Electronic Signature*

Signature:

Fill out the questions below.

Diagnosed Parent Info:

Spouse/Caregiver Registration:

Child Registration:

Informed Consent Agreement*

Release Agreement*

SMS Opt-In*

Consent Electronic Signature*

Signature:

Parent/Guardian Signature:

Fill out the questions below.

Diagnosed Parent Info:

Caregiver Registration:

Child Registration:

Informed Consent Agreement*

Release Agreement*

SMS Opt-In*

Consent Electronic Signature*

Signature:

Parent/Guardian Signature:

Programs

CONNECT

Resources

GIVE

Hope Hub™ Registration

Fill out the questions below.

Diagnosed Parent Info:

Spouse/Caregiver Registration:

Child Registration:

Informed Consent Agreement*

Release Agreement*

SMS Opt-In*

Consent Electronic Signature*

Signature:

Fill out the questions below.

Diagnosed Parent Info:

Spouse/Caregiver Registration:

Child Registration:

Informed Consent Agreement*

Release Agreement*

SMS Opt-In*

Consent Electronic Signature*

Signature:

Parent/Guardian Signature:

Fill out the questions below.

Diagnosed Parent Info:

Caregiver Registration:

Child Registration:

Informed Consent Agreement*

Release Agreement*

SMS Opt-In*

Consent Electronic Signature*

Signature:

Parent/Guardian Signature:

Programs

CONNECT

Resources

GIVE

Hope Hub™
Registration