Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please indicate your background/interest in Tiny Sparks WA *

Please check one or more boxes

High-Risk Pregnancy Family

NICU/SCN Family

Medical Professional

Friend/Supporter

Audio visual consent

I hereby give Tiny Sparks WA my consent for the following persons to be videotaped, audio recorded and photographed during the attendance of a Tiny Sparks WA event or promotion. I understand and agree to the video, audio recording or photographs being taken used for Tiny Sparks WA website, promotional and informational brochures, posters, videos, print and social media. Please note: You are under no obligation, and it is not a condition of membership to agree to the release of images.

Myself

My immediate family

Code of Conduct *

As a member of Tiny Sparks WA Inc, I hereby agree to comply with conditions and uphold the values as detailed in the approved Code of Conduct.

Approval Process *

I agree to a delegate of Tiny Sparks WA contacting me for a phone interview and other appropriate background checks as a condition of this application.