Welcome to the Inheritance of Hope Family!  By filling out the below application you will be considered for our Hope@Home™ weekend, providing your family the opportunity to enjoy hope-inspiring resources and relationships with other families in similar circumstances and our IoH team.

We know you have a lot to deal with now, which is why we have made the application easy to complete online.  In fact, a close friend or family member can assist you with most of the form. 

To finish the application, be sure to click the "Submit" button at the bottom.  Applications are processed and Hope@Home™ weekend dates are offered on a first-come, first-served basis.

If you have any questions during your application process, please do not hesitate to contact Stephen@InheritanceOfHope.org

Applicant First Name (parent with life-threatening diagnosis)

Applicant Last Name

Family Eligibility: Inheritance of Hope's mission is to inspire hope in young families, with children 18 or under, facing the loss of a parent to a life-threatening illness. Does this match your family's situation? yesno

Applicant's Diagnosis

Applicant's Birth Date

Applicant's Gender

Applicant's T-Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

Applicant's Cell Phone Number

Applicant's Email Address

Mailing Street Address

City

State

Zip

For package delivery, any special delivery instructions?

Your spouse/caregiver and children for whom you have legal custody may participate in the Hope@Home™ weekend with you. Please enter the following information for each person planning to participate in your Hope@Home™. Spouse or Caregiver Name

Spouse or Caregiver's Relationship to Applicant

Spouse or Caregiver's Email Address

Spouse or Caregiver's Cell Phone Number

Spouse or Caregiver's Birth Date

Spouse or Caregiver's Gender

Spouse/Caregiver Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

1st Child Name

1st Child Relationship to Applicant

1st Child Birth Date

1st Child Gender

1st Child Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

2nd Child Name

2nd Child Relationship to Applicant

2nd Child Birth Date

2nd Child Gender

2nd Child Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

3rd Child Name

3rd Child Relationship to Applicant

3rd Child Birth Date

3rd Child Gender

3rd Child Shirt Size 5XL 4XL 3XL XXL L M S youth L youth M youth S youth XS

4th Child Name

4th Child Relationship to Applicant

4th Child Birth Date

4th Child Gender

4th Child Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

5th Child Name

5th Child Relationship to Applicant

5th Child Birth Date

5th Child Gender

5th Child Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

6th Child Name

6th Child Relationship to Applicant

6th Child Birth Date

6th Child Gender

6th Child Shirt Size 5XL 4XL 3XL XXL XL L M S youth L youth M youth S youth XS

We will be working on a special surprise and we need some help. In an effort to help us serve your family better, we would appreciate it if you could list three contacts (not household members) who know your family well. 1st Contact Name

1st Contact Relationship the Applicant

1st Contact Phone Number

1st Contact Email Address

2nd Contact Name

2nd Contact Relationship to Applicant

2nd Contact Phone Number

2nd Contact Email Address

3rd Contact Name

3rd Contact Relationship to Applicant

3rd Contact Phone Number

3rd Contact Email Address

Informed Consent Agreement Accept a) I understand, recognize, and agree that Inheritance of Hope employs a variety of facilitators in order to provide a quality experience to all Participants. I understand that I can request information regarding my facilitators' education and experience backgrounds from Inheritance of Hope. b) I understand, recognize, and agree that a safe group environment is created and maintained by both the facilitators and the group members offering mutual respect and trust. Confidentiality is also primary for a safe group environment. Group facilitators are bound by law to maintain confidentiality. Participants are bound by honor to maintain confidentiality. Should I desire to share what I learn in group, I agree to do so without using group members' names or in any way compromising group members' confidentiality. I acknowledge that there are legal and professional limits to confidentiality. I understand that I can request more information about these limits from Inheritance of Hope. c) I understand, recognize, and agree that my children and/or teenagers will have age-appropriate group experiences for healthy emotional processing. The above elements also apply to children and teenager groups. I understand that children and teenagers will not focus on specific details of any parent's illness but will address the fact that all have an ill parent in common. d) I understand and agree to all terms of Hope@Home™ group participation. I also understand and agree that any Participant can contact Inheritance of Hope for more information about any aspect of the group experience.

Release Agreement Accept a) I understand that participation in an Inheritance of Hope Hope@Home™ is purely voluntary. b) On behalf of myself and all the Participants listed on this form, their heirs, personal representatives, guardians, successors, and assigns, I hereby unconditionally, irrevocably, and absolutely release, discharge, and agree to indemnify and hold harmless Inheritance of Hope, its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries, from any and all loss, liability, claims, demands, causes of action, costs or expenses (including attorneys’ fees), damages or suits of any type, whether in law and/or in equity, related directly or indirectly, or in any way connected with the Participants’ participation in the Inheritance of Hope Hope@Home™. c) I understand, recognize, and agree that there are dangers, hazards, and risks associated with participation in the Hope@Home™. I understand that participation in the Hope@Home™ may result in injury, property damage, interaction with persons having potentially communicable diseases, and/or death. I acknowledge that I understand and have fully considered the dangers, hazards, and risks associated with the Hope@Home™ and voluntarily assume the risks associated with participation in the Hope@Home™. I hereby unconditionally, irrevocably, and absolutely release, discharge, and agree to indemnify and hold harmless Inheritance of Hope, its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries, from any and all loss, liability, claims, demands, causes of action, costs or expenses (including attorneys’ fees), damages or suits of any type, whether in law and/or in equity, in the event of injury, property damage, disease, and/or death related directly or indirectly, or in any way connected with the Participants’ participation in the Inheritance of Hope Hope@Home™. d) I understand, recognize, and agree that I am fully responsible for my child(ren) throughout the Hope@Home™. e) By my/our signature(s) set forth below, I/we authorize Inheritance of Hope to photograph, film, and/or electronically record interviews with me/us in such a manner as they choose. I further give permission and consent that any such photographs, films, and/or electronically recorded interviews may be published and used by Inheritance of Hope and its agents to illustrate and promote the Hope@Home™ experience and Inheritance of Hope. f) By my signature set forth below, I the Applicant understand that I am unconditionally, irrevocably, and absolutely authorizing Inheritance of Hope to share the medical information contained in this application with its directors, officers, employees, volunteers, agents, representatives, successors, and assigns, and any parent organizations, affiliates or subsidiaries. g) I agree that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Any claims against Inheritance of Hope arising from or related to this Agreement or the Hope@Home™ must be submitted to binding arbitration in accordance with the applicable rules of the American Arbitration Association. Any arbitration shall be sited in Transylvania County, North Carolina.

I/we hereby warrant that I/we have read the foregoing Agreements and executed them freely and voluntarily. I/we consent to providing my/our legally effective electronic signature(s) by typing full legal name(s) below and entering today's date. Accept

Applicant Signature

Applicant Signature Date

Spouse/Caregiver Signature (If no spouse/caregiver will be included in the retreat, applicant must sign here also.)

Spouse/Caregiver Signature Date

Parent/Guardian Signature of all minor children included in the retreat

Parent/Guardian Signature Date

How did you hear about Inheritance of Hope?

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