The Todd McGovern Legacy Grant Application Process

Todd McGovern Legacy Grant Application

Name

First Name

Last Name

Gender

Female

Male

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Diagnosis

Beginning of Treatment

YYYY

Where are you being treated?

What are your interests, hobbies, preferred activities? Tell us what would make you feel more lively, more positive, and in-control?

What are your plans for the Todd McGovern Legacy Grant? In what ways would this grant benefit you as you undergo cancer treatments? How would this grant affect or inspire others fighting cancer in years to come? Don’t be modest. We want to know how great you are!

Emergency Contact Information

Emergency Contact Name

First Name

Last Name

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone Number

(###)

###

####

Recommendations

Recommendations are required from two sources, preferably non-family members. The recommendations should provide information about your experience battling cancer and should also address your Todd McGovern Legacy Grant proposal. Please send the individuals recommending you the following link to our recommendation form: [[seasit.org/grant-recommendation]]. Ask them to fill out the form and submit it back to Seas It. If you have any questions regarding your recommendations please contact jeni@seasit.org

Sign Our Waiver

WAIVER AND RELEASE FOR GOOD AND VALUABLE CONSIDERATION I, the undersigned, understand that the Grant activity does not replace medical treatment, and I have reviewed my participation in a Seas It Grant program with my primary health care provider. I, the undersigned for myself, my successors, heirs, assigns, executors, and administrators agree that prior to participating in this Grant activity, I will inspect the facilities and equipment to be used and, if I believe any of them are unsafe, I will immediately advise the supervisory person at the facility. I understand that the Grant activity is a potentially hazardous activity, and I hereby voluntarily assume full and complete responsibility for, and the risk of, any injury or accident that may occur during my participation in the Grant. I am physically capable of completing the event. I understand that it is recommended that I discuss my participation with my primary health care provider. If I am aware of or under treatment for any physical infirmity, ailment or illness, I understand that it is my responsibility to have discussed the event and my participation in the event with my medical care provider(s) familiar with such condition. I acknowledge that I, and I alone, am solely responsible for my personal health and safety. I fully understand that I will be engaging in activities that involve risk of injury or death, including economic losses which might result not only from my injuries to myself, including medical or hospital bills, permanent or partial disability or death and damages to my property, real or personal caused by or resulting from my participation in the Event. I agree not to sue Seas It, Seas It’s volunteers, sponsors, employees, directors, officers and agents and their representatives, successors and assigns for any loss, damage, claim or demand arising from or attributable to my participation in the Event, and I hereby release, relinquish, waive and discharge Seas It, Seas It’s volunteers, sponsors, employees, directors, officers and agents and their representatives, successors and assigns from any and all liability, loss, damage, claim or demand arising from or attributable to my participation in the Event. I have consulted with my medical team and it has been determined that I am able to participate in a recreational activity.

Patient Signature

I HAVE READ THIS WAIVER AND RELEASE, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN VOLUNTARILY.

Instructions

Step 1.

Fill out the Todd McGovern Legacy Grant application and submit two letters of recommendation. Recipients of the goods, services and funds offered by Seas It will be selected on a first come, first serve basis without discrimination on the basis of gender, race, religion, ethnicity or sexual orientation.

Step 2.

Once the application is reviewed by Seas It, a Seas It representative will contact you to discuss your application and candidacy for the Legacy Grant. We will notify you of your grant status within one month of your completed application. The Legacy Grant activity must be completed within the calendar year, with funding to be determined by Seas It.

Step 3.

Applications will be accepted throughout the calendar year. If the grant has already been awarded for a given year, applicants can apply for a Seas It Patient/Caregiver Grant, and apply again for the Legacy Grant in future years.

The Todd McGovern Legacy Grant Application Process

Instructions

Step 1.

Step 2.

Step 3.

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