©2013, American Heart Association. Also known as the Heart Fund. 5/13KB-0515

If you have raised $50 or more, you’ve earned a T-shirt! Please mark your size: Youth: q M q L Adult: q S q M q L q XL q XXL q 3XL

O Bobbie Basketball $25.00

Sponsor’s Name PaidCash/Check

or MoneyOrder Donation

TOTALDonations

x

Online Donation

INCLUDEDONATION REPORT

Company Matching Gift

Forms*

$25.00

TOTAL DONATIONS $ $ $ $

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STUDENT’S FIRST NAME _______________________________STUDENT’S LAST NAME ________________________________________

GRADE_______________________ROOM # _____________________TEACHER’S NAME _________________________________________

NAME OF SCHOOL _____________________________________________________________________________________________________

EVENT DATE _____________________________RETURN THIS ENVELOPE TO TEACHER BY THIS DATE __________________________

I’M PLAYING IN HONOR OF ______________________________________________________________________________________________

q I WANT TO GIVE MORE, SO PLEASE DO NOT SEND GIFTS.PLEASE CONVERT ALL CASH TO A CHECK(S) PAYABLE TO THE AMERICAN HEART ASSOCIATION. All donors who make donations online will receive a donation receipt.

*Double Your Donations! Ask your sponsors if they work for a matching gift company and ask for their company form to include in this envelope. Example: $25 donation and the sponsor works for a “Matching Gift Company” = $50 for your total donation. Check out matchinggifts.com/AHA for more information!

heart.org/hoopsThis seal signifies that the American Heart Association - National meets the BBB Wise Giving Alliance’s Standards for Charity Accountability.

PARTICIPANT’S SPONSOR FORMPARTICIPANT’S SPONSOR FORM

HeART HeRO: Colby, Age 10Colby was born with Hypoplastic Left Heart Syndrome. By age 2½, he had experienced five open heart surgeries. He will need a heart transplant in the future, but for now, Colby loves to draw and is quite the artist! Colby also enjoys raising awareness about heart defects and helping to raise money for the American Heart Association.

Here’s how to get started!Return the permission slip so you can participate.

Set a dollar goal and ask friends and family to help you reach it. (Making your own Web page is the fastest and easiest way to raise money!)

Return the collection envelope and have a great time at the event!

Thank-You GiftsThank-You Gifts

If any item becomes unavailable, we reserve the right to offer an alternate item of equal value. These gifts meet the requirements, where applicable, of the Consumer Products Safety Improvement Act and other product safety regulations.

with Online Donations!

BONUS PRIZES

NiNja Duckwith your first ONLINE donation

Mr. cool Duckwith $75 in ONLINE Donations

Raise money online and SAVE LIVES!• Visit heart.org/hoops and click on the

button “Students Sign Up.”

• Join your school’s team and set up your own Web page.

• Email family and friends to raise funds toward your goal. You can even send a personalized Ecard!

• Make fundraising easier by downloading the Jump/Hoops Mobile app.

ReCeIVe “QUACKY” THe HeART HeRO DUCK AND LANYARD WITH YOUR FIRST DONATION OF $5! (see coupon on back)

heart.org/hoops

Plus Gifts 1-7

Quacky Duck aND laNyarD

BouNce Bowl$5 to $14.99 $15 to $49.99

Plus Gift 1

BONUS PRIZEstripes Duck

Not for children under 3 years.

Raise$35 and Get

LEVEL 2

Recommended for ages 3+.Not for children under 3 years.

HooPs t-sHirt BasketBall$50 to $74.99 $75 to $149.99LEVEL 3 LEVEL 4

Plus Gifts 1-2 Plus Gifts 1-3

BONUS PRIZEGlow Duck

Not for children under 3 years.

Raise$100 and Get

Recommended ages 3+.

walkie talkie PowerwiNG$500 to $999.99 $1,000 and UP

Plus Gifts 1-6

LEVEL 7

Recommended ages 6+ Choking Hazard: small parts

LEVEL 8Recommended ages 5+

Do not exceed 143 pounds. Always wear safety

equipment including helmet, knee and

elbow pads.

HeaDPHoNes$250 to $499.99

Max BooM$150 to $249.99

LEVEL 5Plus Gifts 1-4 Plus Gifts 1-5

BONUS PRIZEtrophy Duck

Not for children under 3 years.

Raise$200

and Get

LEVEL 6Recommended ages 6+

Warning: Choking Hazard Small parts and small balls.

Not for children under 3 years

Recommended ages 6+ Choking Hazard: small parts

Plus Quacktastic Award

LEVEL 1

Plus Gifts 1-7

MOISTEN FLAP, FOLD AND SEAL

hoops For heart Parent/Guardian Permission As the parent or guardian of the student listed below (“Child”), I hereby understand and agree that:

1) Events — My Child and I expressly assume all risks, including potential personal injury and fatality, which may arise out of my Child’s participation in any school events that are sponsored by or affiliated with the American Heart Association (“AHA”). Such events may include but are not limited to Football For Heart, Hoops For Heart, Jump Rope For Heart, Red Out, and any other similar sponsored activities that my Child’s school may offer (“Events”). My Child’s school may on its own develop Events that follow the heart-healthy programs of the AHA, may involve online charitable fundraising for the AHA, and any such Events are also covered by this Form.

2) Being Prepared — It is my sole responsibility to ensure that my Child’s clothing and any equipment are properly fitted and appropriate for use in any Event, and that my Child is physically fit and able to participate in any Events. Prior to any Event, I will instruct my Child to stop and request assistance if he/she experiences any adverse physical symptoms such as, but not limited to, dizziness, excessive fatigue, shortness of breath, pain or any other conditions that would make it difficult or unsafe to continue in the Event.

3) Optional Online Participation — Some of the Events may offer the option of my Child being able to register for an AHA online fundraising program. This program allows students to track their individual and team’s progress while having access to the AHA’s educational and fundraising resources. My Child would have the option of including a photo on his/her site as well as sending out emails to family and friends in support of his/her participation. For more information, go to www. heart.org/hoops. I acknowledge the Direct Notice to Parents and Children’s Privacy Statement on that site. I understand and agree that if I do not want my Child to participate in such online activities, then it is my sole responsibility to prevent my Child from doing so.

Release and Indemnity Agreement I agree, for myself, my Child/Ward, and our heirs, executors and administrators, to not sue and to release, indemnify and hold harmless the American Heart Association, Inc., its affiliates, officers, directors, volunteers and employees and all sponsoring businesses and organizations and their agents and employees, from any and all liability, claims, demands, and causes of action whatsoever, arising out of my Child’s participation in any American Heart Association sponsored or affiliated school Events and related activities, including but not limited to on-line activities, whether it results from the negligence of any of the above or from any other cause. This agreement shall be as broad and inclusive as is permitted by the State in which the event is conducted. If any portion of it is held invalid, the balance shall continue in full force and effect. I have read, understand and agree to the terms of this Release and Indemnity Agreement.

Media Release I authorize the use, copyright, or publication of my Child’s name, image or voice while participating in any Event and related activities, as may be captured by photograph or recording in any medium for any purpose, including illustration, promotion or advertisement.

I am the parent or legal guardian of the participant, and I hereby consent to his/her participation in Events and related activities. I have read and explained this Form to my Child, and I hereby agree to all of its terms and conditions on behalf of myself and my Child.

_____________________________________________ ______________________________________________________ ______________________Parent/Guardian’s Printed Name Signature Date

Yes, I will be a parent volunteer and help with this event. I may be reached at this phone number: ___________________________________

_____________________________________________ ______________________________________________________ ______________________Student’s Printed Name Home Room Teacher’s Name Date

__________________________________________________Student’s Signature (required if 18 years or older)

Although our financial report is always available upon request, some states require us to advise you that a copy of our financial report is also available through their offices.AHA, State of California – 79% of every dollar we spend goes directly towards research, public health education, professional education and training, and community service programs. Your donation is tax deductible.

AHA, STATE OF FLORIDA - AMERICAN HEART ASSOCIATION OFFICES THROUGHOUT FLORIDA MEET ALL REQUIREMENTS SPECIFIED BY THE FLORIDA SOLICITATION OF CONTRIBUTIONS ACT. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL FREE WITHIN THE STATE, 1-800-435-7352. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL OR RECOMMENDATION BY THE STATE. REGISTRATION #CH-430.

AHA, State of Georgia – A detailed summary of the Association’s programs and funding will be provided upon request.

AHA, State of Maryland – A copy of the current financial statement of The American Heart Association is available by writing 4217 Park Place Court, Glen Allen, VA 23060 or by calling (804) 747-8334. Documents and information submitted under the Maryland Solicitations Act are also available, for the cost of postage and copies, from the Maryland Secretary of State, State House, Annapolis, MD 21401, (410) 974-5534.

AHA, STATE OF MISSISSIPPI – The official registration and financial information for the American Heart Association may be obtained from the Mississippi Secretary of State by calling 1-888-236-6167. Registration by the Mississippi Secretary of State office does not imply endorsement by the Mississippi Secretary of State.

AHA, STATE OF NEW JERSEY – INFORMATION FILED WITH THE ATTORNEY GENERAL CONCERNING THIS CHARITABLE SOLICITATION AND THE PERCENTAGE OF CONTRIBUTIONS RECEIVED BY CHARITY DURING THE LAST REPORTING PERIOD THAT WERE DEDICATED TO THE CHARITABLE PURPOSE MAY BE OBTAINED FROM THE ATTORNEY GENERAL OF THE STATE OF NEW JERSEY BY CALLING 201-504-6215 AND IS AVAILABLE ON THE INTERNET AT WWW.STATE.NJ.US/LPS/CA/. REGISTRATION WITH THE ATTORNEY GENERAL DOES NOT IMPLY ENDORSEMENT.

AHA, State of New York – On request, the Association will supply a copy of the complete financial statement. Please write to: the American Heart Association, Founders Affiliate, PO Box 3049, Syracuse, New York 13220-3049 or the New York State Attorney General’s Charities Bureau, 120 Broadway, 3rd Floor, New York, New York 10271 or visit charitiesnys.com.

AHA, STATE OF NORTH CAROLINA – FINANCIAL INFORMATION ABOUT THIS ORGANIZATION AND A COPY OF ITS LICENSE ARE AVAILABLE FROM THE STATE SOLICITATION LICENSING BRANCH AT 919-807-2214. THE LICENSE IS NOT AN ENDORSEMENT BY THE STATE.

AHA, State of Pennsylvania – The official registration and financial information of the American Heart Association, Inc.may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania at 1-800-732-0999.Registration does not imply endorsement.

AHA, State of Virginia – A financial statement is available upon written request, from the Virginia Office of Consumer Affairs, PO Box 1163, Richmond, VA 23218. 1-800-552-9963 or within the Richmond, VA area 1-804-786-2042.AHA, State of Washington – The AHA, State of Washington is registered with the Secretary of State, Charities Division.Information is available by calling the Office of Secretary of State at 1-800-332-4483 or visiting www.sos.wa.gov/charities.

AHA, State of West Virginia – West Virginia residents may obtain a summary of the registration and financial documents from the Secretary of State, State Capitol, Charleston, West Virginia 25305. Registration does not imply endorsement.

AHA, State of Wisconsin – The American Heart Association meets all nine standards of philanthropy of the National Charities Information Bureau, which judges if charities fulfill their obligations to donors and the public. Your contribution will help fund research and education to fight heart disease and stroke. For a copy of our financial statement, write to: Development Department, American Heart Association, Midwest Affiliate, 1555 N. Rivercenter Drive Ste. 212, Milwaukee, WI 53212

• Uncomfortable pressure, squeezing, fullness or pain in the center of the chest that lasts more than a few minutes or goes away and comes back.

• Pain or discomfort in one or both arms, the back, neck, jaw or stomach.

• Shortness of breath with or without chest discomfort.

• Breaking out in a cold sweat, nausea or lightheadedness.

Not all of these warning signs occur in every heart attack. If some start to occur, get help immediately. Heart attacks are a

medical emergency — CALL 9-1-1.

Heart Attack Warning Signs Parents, When your child raises $5 for Hoops For Heart — fill out this coupon, tear it off and send it back to school with your child. They will receive their first Heart Hero Duck, Quacky, as well as a lanyard!

My child has raised at least $5 in donations for Hoops For Heart.

Signed by (his/her parent)