Join the Junior Ambassadors

Body

Parent/Guardian Consent and Release Form

The Ambassadors are a group of supporters, both adults and children, who have the opportunity to become further engaged with Children’s Hospital Los Angeles (“CHLA”). The Ambassadors offers special recognition and engagement opportunities to friends of CHLA who give or fundraise $1,000 or more annually. Children are encouraged to participate in many facets of the Junior Ambassadors Program (“Program”), including service and education. As part of their Junior Ambassadors role, they are given an opportunity to be a representative and fundraiser for CHLA. At the end of the Junior Ambassador Term, all Junior Ambassadors who pledge to be an Ambassador will be honored and thanked as participants regardless if they meet the $1,000 goal. Due to this goal, the Program is suggested for children 12 years of age or older. However, children of all ages are welcome to participate in the Program, and it is up to the parent/guardian to determine their child’s interest.

Junior Ambassador Information

Child First Name

Child Last Name

Email Address

Address

City

State

(two characters)

Zip

Age

Date of Birth

(mm/dd/yyyy)

Grade

Name of School

Polo Shirt Size

Are You a New or Returning Ambassador?

I"m new

I"m a Returning Ambassador

If returning, what year did you become a Junior Ambassador?

Reason you want to become a Junior Ambassador

Are you a patient family?

Yes

Prefer Not to Answer

If you are fluent in a language other than English, please specify

Parent Information

Parent 1: First Name

Parent 1: Last Name

Parent 1: Email Address

Parent 1: Phone Number

(xxx) xxx-xxxx

Parent 1: Address

Parent 1: City

Parent 1: State

(two characters)

Parent 1: Zip

Parent 2: First Name

Parent 2: Last Name

Parent 2: Email Address

Parent 2: Phone Number

(xxx) xxx-xxxx

Parent 2: Address

Parent 2: City

Parent 2: State

(two characters)

Parent 2: Zip

Ways you would like to be involved (please check all that apply)

Pledge

I pledge to help the patients and their families at Children’s Hospital Los Angeles by raising $1,000.

I would like to help fulfill my pledge by:

Creating a personal fundraising page at CHLA.org/SUPPORT

Collecting donations for activities that I accomplish, such as a sports goal, bike rides, walks, etc.

Collecting donations for my birthday instead of gifts

Holding a small fundraiser or event, such as a car wash, lemonade stand, craft boutiques, etc.

Other

If Other, please specify

Waiver and Agreement

Waiver

You understand that participation in the Program is completely voluntary and CHLA does not require your child’s participation in the Program. You understand that CHLA may decide not to accept your child into the Program and CHLA may modify or end your child’s participation in the Program at any time in its sole discretion. You and your child assume all risks and liabilities arising from or related to participation in the Program. You, your child, and your heirs and assigns, release and discharge CHLA and its directors, trustees, employees, staff, and volunteers from all claims and liabilities arising from your child’s participation in the Program. You further agree to hold harmless and indemnify CHLA and its directors, trustees, employees, staff, and volunteers for all costs, claims, and liabilities arising from or related to you or your child’s participation in the Program. You are responsible at all times for monitoring your child’s participation in the Program, and you and your child agree to abide by the terms and condition set forth in this Consent and Release Form and all CHLA procedures and policies.

You certify the following: you are the parent or legal guardian of the child named above; you and your child are not agents, or representatives of CHLA; all information that you have provided to CHLA is correct; and your child has your permission to engage in all the activities of the Program. You have fully read, understand, and voluntarily agree to this Consent and Release Form. I acknowledge and accept that this Consent and Waiver Form is intended to be as broad and inclusive as permitted by the laws of the State of California and that if any portion of this Consent and Waiver Form is invalid, the remainder will continue in full legal force and effect.

I agree to these terms and conditions

Parent/Guardian Consent and Release Form

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