Cleft Family Picnic

We are excited to celebrate our children born with cleft lip, palate, and other craniofacial differences at our first picnic! Where kids can do what they do best: have fun. Where parents can connect with others on a similar journey. Where new friendships begin!

Ramada 1 is ADA Accessible, has electrical outlets, 2 picnic tables, lights, BBQ grills, a drinking fountain, attached bathrooms, and is right next to the playground.  

As there are only two picnic tables available, families should plan to bring chairs/picnic blankets. 

Light snacks will be provided.

Register by Friday, October 9th

Patients attending the event are invited to participate in a short video that will be used to help prepare future patients for their scoping procedures. Patients with a signed photo/video release are welcome to take part.

Informed Consent to Photograph or Record | Cleft Family Event

Children's Clinic Patient Name

I consent on behalf of the above-named patient to video recording by Children's Clinic staff.

I consent on behalf of the above-named patient to video recording by Children's Clinic staff.

I agree the resulting images or recordings may be used for Children’s Clinics publicity or marketing (brochure, pamphlet, bulletin board, display, informational video, magazine article)

I agree the resulting images or recordings may be used for Children’s Clinics publicity or marketing (brochure, pamphlet, bulletin board, display, informational video, magazine article)

I prefer to opt out of participating in this video on behalf of the above-named patient.

I prefer to opt out of participating in this video on behalf of the above-named patient.

I understand I have the right to reverse this consent, in writing , at any time before the image or recording is used for the purpose(s) indicated above.

I understand I have the right to reverse this consent, in writing , at any time before the image or recording is used for the purpose(s) indicated above.

Name of Patient, Parent/Guardian, or Legally Authorized Representative

Relationship to Patient

Signature of Patient, Parent/Guardian, or Legally Authorized Representative

Date

Name of Witness to Signature

Signature of Witness

Date

Submit