Forget-Me-Not Friends Club Registration

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Register yourself or a loved one with a disability to become a member of the FORGET-ME-NOT FRIENDS CLUB, a service of the Forgotten Wishes Foundation®. All ages are welcome!

Our Mission:
The Forgotten Wishes Foundation® is a 501(C)3 established by Robert and Lisa Dempsey in Houston, Texas. We want to create a sense of belonging for people with disabilities by remembering them with personalized birthday and holiday wishes, small gifts, and events to celebrate their lives. Visit us online at www.forgottenwishesfoundation.org for more information.

Club Member's FIRST NAME *

Club Member's LAST NAME *

Address (street number and name) *

City *

State *

Zip Code *

Where will the club member's mail be received? *

Residential Home

Group Home, Assisted Living Facility, or Nursing Home

Apartment

Foster Home

Required

Member's Date of Birth Month/Day (MM/DD) *

Club Member's Email Address

Club Member's Mobile Phone to Receive Texts

Help us get to know the club member better. Tell us about any special interests, favorite sports teams, movie characters, activities, etc. When we can we will use this to personalize mailings. *

What is the primary disability of the Club Member/Recipient?

Who is completing this registration? *

I am a disabled person over the age of 18.

I am the legal guardian or authorized representative of a person with a disability.

Relationship to Club Member *

Self

Parent or Legal Guardian

Residential Facility or Service Provider

Authorized Agent

Required

Authorization of Membership

I authorize the Forgotten Wishes Foundation® to use the contact information provided to enroll the named member in the Forget-Me-Not Friends Club program. I understand that I am agreeing to release contact and other information solely for the purpose of the activities of the Forgotten Wishes Foundation® programs and the Forget-Me-Not Friends Club. I may revoke this authorization at any time by notifying the Forgotten Wishes Foundation® in writing. If I revoke the authorization, I understand that it will have no effect on the actions the Forgotten Wishes Foundation® took in good faith before receiving the revocation. By typing my name in the following box I am affirming that I am a person with a disability over the age of 18, a legal guardian, or an authorized agent for a member with a disability.

Type Your Name to Agree to the Authorization *

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