EmailMe Form - London BrainWAVE/Beyond The WAVE

Guardian(s) Information *

First Last

Date of Birth *

MM / DD / YYYY

Email *

Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

To help us determine the number of adult tickets needed, are there any additional parents/guardians we should include in your family's profile? *

Yes / Oui

No / Non

Additional Parent/Guardian Details: Please provide the full name, date of birth, and email address for each additional adult.

Patient/Survivor Name *

First Last

Date of Birth *

MM / DD / YYYY

Do you require any accommodations for accessibility? /

*NOTE: The Box Suite is wheelchair accessible, but please review the venue accessibility policy: https://www.canadalifeplace.com/arena-info/accessible-seating *

Yes

No

If yes, kindly provide further details.

Do you have any specific dietary restrictions? *

Yes

No

If yes, kindly provide further details.

To help us determine the number of other tickets needed, are there any additional siblings we should include in your family's profile? *

Yes

No

Additional Sibling Details: Please provide the full name and date of birth for each additional youth/adolescent.

Please remember this opportunity is only available to a maximum of four people.

STATEMENT OF CONFIDENTIALITY: Participants have the responsibility to keep all personal information that is shared during the event in strict confidence (i.e., names, contact information, personal details, photographs, etc.). Confidentiality is vitally important and establishes trust among all participants. This ensures everyone can freely express their thoughts, knowing their privacy will be respected. Brain Tumour Foundation of Canada staff, facilitators, and volunteers are required by provincial law to report any information that is shared regarding imminent self-harm, imminent harm to others, and child-abuse or neglect. *

I acknowledge and agree to maintain the confidentiality of all personal information shared during the event.

STANDARDS OF BEHAVIOUR: All participants are expected to adhere to the following standards of behaviour before and during events:
- Prohibition of Substances: The consumption of illicit drugs and/or alcohol is strictly forbidden.
- Respectful Communication: Inappropriate language, including offensive or discriminatory remarks, is not tolerated.
- Appropriate Conduct: Any form of inappropriate actions, including aggressive or disruptive behaviour, is prohibited.
Failure to comply with these standards may result in the individual being ineligible for any future event(s). These measures are in place to ensure a safe, respectful, and enjoyable experience for all participants. *

I acknowledge and agree to adhere to the Standards of Behaviour.

EVENT WAIVER: I hereby release, indemnify, and agree to hold harmless Brain Tumour Foundation of Canada, and its corporate sponsors, cooperating organizations, and any other parties connected with this program/event offering in any way from and against any costs, suits, liability, and any injury, harm, loss, or damage suffered or sustained as a result of my participation in this event offering or any activities associated therewith. *

I acknowledge that by participating in this event, I release, indemnify, and hold harmless BTFC and its partners from any costs, liability, injury, harm, loss, or damage arising from my participation.

Emergency Medical Treatment *

I hereby consent to and permit emergency treatment in the event of illness or injury.

MULTIMEDIA WAIVER: We, the undersigned, hereby approve the use of our family story and photos/videos taken on behalf of Brain Tumour Foundation of Canada, to be reproduced for inclusion in promotional materials, including, but not limited to the newsletter, website, media, direct mail asks, annual report and the case for support for Brain Tumour Foundation of Canada. We, the undersigned, hereby understand that these pictures/videos will be used as mentioned above unless we request their removal.
We, the undersigned, hereby acknowledge and agree that we are not entitled to and will not claim any compensation or other payment from Brain Tumour Foundation of Canada or Cooperating Organizations for such publication or use. *

I confirm my consent for the use of our family story, photos, and video footage for the purposes outlined above.

By completing this form, we will add your Family Profile to our BrainWAVE/GOcervo family list, enabling you to receive updates about upcoming events and resources. To learn more about our BrainWAVE/GOcervo program, please visit: /