Virtual Muscle Dream Application

Please return all completed sections – receipt of your completed forms will be acknowledged. Should you have any questions ref the completion of this and/or any of the sections, please contact at email to: info@musclehelp.com – thank you.

SECTION ONE = Muscle Dream Beneficiary Information

Virtual Muscle Dream beneficiary

Information about Muscular Dystrophy

Beneficiary Family / Carer information – Address + Contact + Vehicle Details

Virtual Muscle Dream Nominator / Referrer

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

From another familyWord of mouthAnother Muscle Dream recipientFundraising eventInstagramHospiceFacebookTwitterMHF charity leaflet

SECTION TWO = Additional Information

As part of the charity’s new virtual Muscle Dream activities, we would like to get to know you a little more before we virtually meet you – please use this section to tell us about yourself. This will help us with planning & will be kept in the strictest of confidence in line with current GDPR legislation. We take your privacy very seriously. No data or information will be shared with any 3rd parties.

About Your Household

Are you planning on shielding for the foreseeable future or until a vaccine is found?:

Do you have access to a garden that is accessible without entering the property?:

Do you have a driveway and/or any off-road parking?:

T-shirt Sizing

T-shirt size:

Favourite Take-Out

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

Household Technology

Would you be able to participate in a standalone video-conferencing call?:

Do you have a computer / laptop?:

Do you have access to a smartphone?:

SECTION THREE = Beneficiary Profile

Please answer the questions below – invite your family or perhaps some of your friends to participate in this! Above all, be sure you have some fun in answering them!

Name one streaming provider below that you might enjoy a subscription to:

If you love music and given the opportunity, would you enjoy a subscription to either:

If you want to learn more about our BIG 657 Quiz Event contact us here

If you want to learn more about our 'In Conversation With' series click here

SECTION FOUR = 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

Witness Signature

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:

Other Adult Participant, if any

Witness Signature:

Parent/Legal Guardian of Other Minor, if any

Witness Signature:

SECTION FIVE = 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

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:

TELEPHONE/SMS

POST

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.