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Patient Onboarding

Child's First Name

Last Name

Date of birth

Gender

Primary Language

Address

Address Line 1

Address Line 2

County

Eircode

Parent/Guardian details

Please provide at least one parent/guardian details

Parent/Guardian 1 Name

Parent/Guardian 1 Last Name

Contact phone no.

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Contact phone no.

Child's primary diagnosis

Number of siblings under 18 yrs

Your Child's preferences

Favourite sports

Favourite Teams

Favourite stars

Has your Child previously received a trip abroad from a charity?

Date of previous trip?

Details of previous trip

Agreements

I understand that any personal data provided as part of this application, including special category data contained in my medical record, will be processed by Michael's Fan Club in the manner described in the privacy policy and I consent to such processing. Full details are available in the privacy policy on our website, www.michaelsfanclub.ie.

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All information provided in this form is handled in full compliance with current data protection legislation including the EU Regulation 2016/679 General Data Protection Regulation (“GDPR”). Full details are available in the privacy policy on our website, www.michaelsfanclub.ie

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I agree to allow personal information about me to be shared with third parties as necessary for activities to be fulfilled.

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I consent that my personal data may need to be transferred outside of the EEA, in order to facilitate the fulfilment of activities. Any such transfers will use appropriate data protection safeguards, in compliance with GDPR

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We/I, the Child's Parent(s)/Guardian authorise Michael's Fan Club to obtain all medical information about the Child which Michael's Fan Club may feel necessary for consideration or fulfilment of activities and authorise all physicians and medical care providers including the Child’s Physician, to provide Michael's Fan Club with all medical information regarding the Child

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We/I hereby confirm and undertake that all parents / legal guardians of the wish child have signed this form and that there are no legal, access, guardianship, care or custody arrangements in place which may impact or be relevant to the fulfilment of any activity by Michael's Fan Club

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We/I confirm that the Child is an active patient of St John's Ward, Children's Health Ireland (CHI) at Crumlin and that the information in this application is complete and true, to the best of my/our knowledge

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First Parent's / Legal Guardian's Signature:

Date / Time

Second Parent's / Legal Guardian's Signature:

Date / Time