WP E-Signature by Approve Me - Sign Documents Using WordPress -

Spring NY Pink Bag Event Application

Please review the submitted information and sign below.

I understand that I am applying to participate in the UBCF gifts-in-kind giveaway which provides those affected by breast cancer the opportunity to receive donated Product/s during an event held at a location in Huntington Station, NY.

I understand and agree the processing of my application to attend United Breast Cancer Foundation’s (UBCF) Pink Bag Event® may take up to 10 (ten) business days.

I understand and agree that I will be notified via email and/or text message regarding the status of my application once it has been processed.

I understand and agree that UBCF only accepts completed applications in 1 (one) online application, and only 1 (one) application per household

I understand and acknowledge that applications are processed and approved on a first come, first served basis, and by submitting my application I am not guaranteed to be approved.

I accept the product/s in "as is" condition. UBCF assumes no responsibility for the Product's present or future condition and I hold harmless UBCF, and its related and affiliated individuals and donors, from any injury or liability which may occur directly or indirectly as a result of my use of the Product/s. UBCF is not the manufacturer of the Product/s. I acknowledge that no representations are being made by UBCF as to the condition, use or maintenance of the Product/s. I state that I have the opportunity to inspect the Product/s and that I believe in my sole judgment that the Product/s is useful and acceptable to me. I acknowledge that the Product/s may be in new, refurbished, or used condition

I agree that no goods, services or other benefits were exchanged in return for the Product/s. I may not sell, trade, barter or otherwise distribute the Product/s to any other person or entity. I shall utilize the Product/s solely for my personal use.

I understand that the event will take place on March 23 through March 27 (subject to change) in Huntington Station, NY and that if approved I will be assigned an appointment (pick-up time) between the hours of 8 AM and 5 PM EST that cannot be changed. I will bring the approval information and photo identification with me and show it as requested or, notwithstanding having been approved, I will not be allowed to participate. At the event I will conduct myself properly and will follow the reasonable instructions of UBCF.

First Name

Last Name

Birth Date

Phone

Address

City

US States

Zip

County

Gender

Ethnicity

When were you diagnosed with Breast Cancer?

Are you currently under treatment for Breast Cancer

Are you in remission from Breast Cancer?

Total number of people in your household?

Total number of children 18 or under in your household

Total annual household income (wages, social security, unemployment, alimony, child support, etc.)

How did you hear about UBCF?

Have you received product at a previous UBCF event?

Please share with us how this donation would support you on your breast cancer journey.

Would you agree to share your experience with UBCF?

I acknowledge that I will pick up my product/s on the day of the event.

IMAGE RELEASE. For good and valuable consideration, the receipt and sufficient of which I hereby acknowledge, I give and grant the United Breast Cancer Foundation (UBCF), and all those acting on its behalf, the absolute right and permission, with respect to the photographs and videos UBCF has taken of me and testimonials I have submitted to UBCF (the “Content”), to use the Content in connection with furthering the mission of UBCF in any and all ways, formats and media UBCF determines in its sole discretion. I hereby release, discharge and agree to save UBCF, all those acting on its behalf and all those for whom UBCF is acting, from any and all claims and demands arising out of or in connection with the use of the photographs, video, and or testimonial, including any and all claims for libel. I am of legal age and have read the foregoing and fully understand the contents thereof. Please select one:

I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.

File Upload - Dr. Letter or pathology report

File Upload - HIPAA Compliant Authorization Form

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

March 5, 2024 12:33 pm EDT

Spring NY Pink Bag Event Application Uploaded by United Breast Cancer Foundation - noreply@ubcf.org IP 93.86.241.70