Register My Own Wishadmin2020-07-28T07:32:00+00:00 Wish Granting From Basic Information Of The Wish Child Gender* Male Female Name of Hospital File NoName of Child* Disease* Date of Birth MM slash DD slash YYYY Age* Father's Name* Mother's Name* Guardian Name* Relationship* No. of Siblings*Permanent Address* Phone No*Language Temp Address if staying for treatment* 1) 2) 3) Wish Team (Name of volunteer) Medical Eligibility Form (To be signed by the physician/Medical Officer of the patient) This Medical Eligibility Form must be completed & signed by the Child's physician. This Medical Eligibility Form is being signed in connection with a wish request that may be granted by the Make-A-Wish Foundation Pakistan.Patient's Name* Date of Birth Illness Patient's Physician Dear Doctor, Please indicate your determination by checkig the appropriate box.Physician certifies that condition listed below been met. Physician certifies that condition listed below been met. 1. Physician is familiar with Child's physical condition and the Child has been diagnosed at the time of referral with an illness on the Medical List of the Make A Wish Foundation Pakistan. 2. Physician is familiar with Child's physical condition and the Child has been diagnosed at the time of referral with a medical condition that is considered life-threatening.Physician identifies the following medical restrictions and needs that must be considered in fulfilling the wish:Physician is familiar with patient's physical condition and certifies that patient is not medically eligible at this time.* Physician is familiar with patient's physical condition and certifies that patient is not medically eligible at this time. Space for any note by the doctor:Name of the Doctor My Favorite Color Music Book/Story Singer Game Movie Class/Subject TV Show Teacher Actor/Actress Food Sport/Team Restaurant Cake/Chocolates When I am at home I like to... Listen to Music Watch Tv Play Indoor Game Read Books In my Spare time I really like too:My First Wish is:I Chose this wish because:If my first wish cannot be granted, my second wish is:I Chose this wish because:Declaration by Parent* Please Check Declaration by Parent(s) Legal Guardian for Access to Medical Information, Liability release and Publicity Authorization Make A Wish Foundation Pakistan as well as Make A Wish International °, all affiliates to Make A Wish International®, all of their Volunteers, Officers, Directors and Agents(Make A Wish) have been asked to fulfill as wish for the above mentioned child. We the wish participants (collectively with wish child referred to as Participants) A) B) a) Consent to access medical information: The child's Parent(s) authorize Make A Wish to obtain al medical information about the Child which Make A Wish may feel necessary for consideration of fulfillment of the wish and authorize all physicians and medical care providers including the Child's Physician, to provide Make A Wish with all medical information regarding the Child. b) Consent to Liability release: We, the Parent(s)/ legal guardian(s) of minor Participants, and other adult Participants, if any understand that involvement in the wish may involve risk of injury or harm to the Participants and agree that this risk is fully assumed by the parent(s)/legal guardian(s) of minor Participants if any. Additionally, in consideration of Make A Wish considering the wish, and if it so determines granting the wish, parent(s)/ legal guardian(s) of minor Participants, if any hereby release and agree to hold Make A Wish harmless for, from and against any and all liability, damages and claims of any kind, known and unknown, which may be connected with, result from, or arise our of the consideration, preparation, fulfillment or participants in the wish, as currently requested or as altered n the future. This includes, but is not limitedto, liability, damages and claims resulting from economic loss, physical injury, illness or death. c) Consent to Disclosure/ Publicity Authorization: We, the parent(s)/ legal guardian(s) of minor participants and other adult participants if any, further understand that involvement in the wish may result in publicity whether or not Make A Wish actively takes step to publicize the wish. Additionally, in consideration of Make A Wish may consider the wish, if so determines granting the wish. The parent(s)/legal guardian(s) of Minor Participants and other adult Participants, if any hereby release and agree to hold Make A Wish harmless for, from and against any and all liability, damages and claims of any kind, known and unknown, which may be connected with result from or arise our of the use, distribution or disclosure of any photographs, films, videotapes, electronic recordings, art work or other information regarding Participants and the wish through any media whatsoever including but not limited to the Internet, electronic media and print publications. We, the Parent(s)/ legal guardian(s) of other minor Participants, if any, and other adult Participants, if any ("Other Participants") acknowledge reading, understanding and agreeing to give out consent to condition mentioned. All the above Only for and are signing below to bind themselves, their minor/ children, their heirs, successors, assigns and estates. We also confirm reading. Understanding/ the above readout to us and explained the same content in Other participants agree that no modification of this form as been made orally or in writing.Parents / legal Guardian (Name) & Signature with date: In presence of (name & signature with date) Consent form explained by (name of volunteer & signature with date)
