Virtual Laughter Muscle Dream Programme – Applications Now Closed

SECTION ONE = Muscle Dream Beneficiary Information

Virtual Muscle Dream Beneficiary

Information about Muscular Dystrophy

Beneficiary Address + Contact Details

Indicate below where you heard about the Muscle Help Foundation (MHF) charity

From another familyWord of mouthAnother Muscle Dream recipientFundraising eventInstagramHospiceFacebookTwitterMHF charity leaflet

Favourite Take-Out

What is you and your family’s favourite take-out meal?

Household Technology

Will you be able to participate in a standalone video conferencing call on Zoom, the platform being used for this virtual Muscle Dream programme?

---YESNO

Do you have a computer / desktop / laptop / smartphone?

---YESNO

Virtual laughter Muscle Dream - Gift Card / Voucher Options (£50 value)

In the menu below, select your preferred option. You will only be able to choose one from the list below:

---GAME gift cardAmazon.co.uk Gift CardMarks & Spencer Gift VoucherArgos Gift cardHMV Gift CardOne4all Gift CardH&M Gift CardOnline Escape Room Bundle for up to 6 Players at The Panic Room via Red Letter Days

SECTION TWO = Liability Release & Disclosure

The Muscle Help Foundation and all affiliates / identities / bodies / partners, of The Muscle Help Foundation or MHF including all associated brands ie. Muscle Dreams and Muscle Warriors, all of their volunteers, officers, directors, employees and agents ("The Muscle Help Foundation") will be delivering a virtual Muscle Dream experience for:

Muscle Dream participants, referred to herein as ‘a participant’ and/or ‘the beneficiary’:
Parent(s)/legal guardian(s) of minor participants, and other adult participants, if any, understand that involvement in the Muscle Dream may involve risk of injury or harm to the participants and agree that this risk is fully assumed by me/us, and other adult participants, if any.

Additionally, in consideration of the Muscle Dream experience, and if it so determines, delivering the Muscle Dream, I/we and other adult participants, if any, hereby release and agree to hold The Muscle Help Foundation 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 out of the consideration, preparation, fulfilment or participation in the Muscle Dream, as currently requested or as altered in the future.

This includes, but is not limited to, liability, damages and claims resulting from economic loss, physical injury, illness (due to for example cold/hot weather), or death.

Publicity / PR / Media Exposure

Parent(s)/legal guardian(s) of minor participants, and other adult participants, if any, further understand that involvement in the Muscle Dream may result in publicity, whether or not The Muscle Help Foundation actively takes steps to publicise the Muscle Dream experience or not.

Additionally, in consideration of the Muscle Dream experience, and if it so determines, granting the Muscle Dream, I/we and other adult participants, if any, hereby release and agree to hold The Muscle Help Foundation 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 out of the use, distribution or disclosure of any photographs, films, videotapes, electronic recordings, art work, or any other information regarding participants and the Muscle Dream, through any media, be it online or offline such as social posts whatsoever, including but not limited to the internet, electronic media, and/or any print publications.

Disclosure Authorisation

The beneficiary’s child's parent(s)/legal guardian(s) authorise The Muscle Help Foundation to obtain any medical information about the delivery of this virtual Muscle Dream experience which they may feel necessary for consideration or fulfilment of this event. Information obtained in this way will be kept within the charity in line with strict data protection guidelines.

Required Signatures:

I/we acknowledge reading, understanding, and agreeing to the conditions of this Liability Release and Disclosure Authorisation and are signing below to bind themselves, their minor children, their heirs, successors, assigns and estates.

I/we agree that no modification of this Liability Release and Disclosure Authorisation has been made orally or in writing. (In cases of joint custody BOTH parents to sign)

Parent/Legal Guardian of recipient

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

Parent/Legal Guardian of recipient

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

Witness Signature

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

Witness Signature

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

I/we and, if any, other adult participants, (“other participants”) acknowledge reading, understanding, and agreeing to the conditions of this Liability Release and Disclosure Authorisation and are signing below to bind themselves, their minor children, their heirs, successors, assigns and estates. Other participants further acknowledge, understand, and agree to be bound by the publicity authorisation selection of the child’s parent(s)/legal guardian(s). Other participants agree that no modification of this Liability Release and Disclosure Authorisation has been made orally or in writing.
Other Adult Participant, if any

Witness Signature:

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

Other Adult Participant, if any

Witness Signature:

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

Parent/Legal Guardian of Other Minor, if any

Witness Signature:

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

SECTION THREE = GDPR Contact Permission + Preferences

In line with General Data Protection Regulation (GDPR) compliance and regulations, The Muscle Help Foundation (MHF) requires your consent to contact you about this virtual Muscle Dream event and / or any associated activities, in addition to including any future comms such as charity updates ie. news items, fundraising, campaigns or online events such as quizzes or broadcast initiatives.

By giving MHF your consent, the charity will hold your data securely. You can opt out of our monthly e-mail updates at any time. The charity will never pass your details on to any 3rd party for their marketing purposes. We will only ever contact you through the communication channels that you have explicitly given your consent for, in line with the stated preferences below.

YOUR SIGNATURE HERE

Sign in the white space below using your cursor if on destop or your finger if on mobile/tablet devices:

I consent to be contacted by The Muscle Help Foundation (MHF) about its charitable activities, by:

Please circle either YES or NO for one or more of the different points of contact below:

EMAIL

---YESNO

TELEPHONE/SMS

---YESNO

POST

---YESNO

Address

I understand that by completing and signing this form, I am giving consent to The Muscle Help Foundation (MHF) to contact me by email, phone or by post in order to stay in touch with the activities of the charity.