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Jacob's Chance Birthday Club!

Thanks for joining the Jacob's Chance birthday club! This birthday club cycle runs from July 2021-June 2022. We're excited to help make your special day extra special this year, with lots of surprises! By joining the clubm on your birthday, Jacob's Chance will:

- Give you a shoutout on social media (Facebook and Instagram)

- Featured you in our weekly newsletter

- Send you a special video greeting through email

- Deliver a gift straight to your doorstep!

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Participant Information
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First Name
Last Name
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(mm/dd/yyyy)
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country


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Tell us a little about your participants interests and their favorite activities that might help us pick out a gift they'll love!
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Any other useful information that'll help us help to make their day special?
Parent/Guardian Information
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First Name
Last Name
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Media Waiver
Jacob’s Chance has my permission to use my or my child’s photograph publically to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
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First Name
Last Name
Media Waiver
Jacob’s Chance has my permission to use my and/or my child’s photograph publically to promote the organization. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
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First Name
Last Name