Media Release Form

Help others understand the realities of childhood cancer. By signing our consent form, we can share your story to amplify the need for more research funding, better treatments and program support for kids and families facing cancer.

General Audience

If you are an adult filing this release for yourself, please use the General Release Form.
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Families of Children with Cancer

If you are an adult filing this release for your child, please use the Child Release Form.
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General Media Release Form

General Release Form

"*" indicates required fields

Children's Cancer Research Fund Authorization for Photography, Filming or Interviewing & Photo Sharing

I hereby expressly grant to Children's Cancer Research Fund the right to make, use and/or publish information, photographs, or any other reproductions of my physical likeness for communications efforts, such as pamphlets, booklets, videotapes, audiotapes, slideshows or Children's Cancer Research Fund’s Internet Web site, and social media sites.

In addition, I expressly grant this right to be used for educational, marketing and/or promotional information by Children’s Cancer Research Fund for its professional and staff communications, public relations, marketing (including social networking websites such as YouTube, Facebook, and Instagram), and fundraising appeals.

I understand that Children’s Cancer Research Fund shall not be responsible for external media’s use of any films, photographs or interviews, or any information that I have consented to release.

Children’s Cancer Research Fund may use resulting media coverage in its internal or external promotional activities.

Indicate any limitations or NONE.

Contact Information

Name*
Address*
Consent*
Today's Date*
This field is for validation purposes and should be left unchanged.

Media Release Form for Families of Children with Cancer

PCF release form

"*" indicates required fields

Children's Cancer Research Fund Authorization for Photography, Filming or Interviewing & Photo Sharing

I hereby expressly grant to Children's Cancer Research Fund the right to make, use and/or publish information, photographs, or any other reproductions of my physical likeness for communications efforts, such as pamphlets, booklets, videotapes, audiotapes, slideshows or Children's Cancer Research Fund’s Internet Web site, and social media sites.

In addition, I expressly grant this right to be used for educational, marketing and/or promotional information by Children’s Cancer Research Fund for its professional and staff communications, public relations, marketing (including social networking websites such as YouTube, Facebook, and Instagram), and fundraising appeals.

I understand that Children’s Cancer Research Fund shall not be responsible for external media’s use of any films, photographs or interviews, or any information that I have consented to release.

Children’s Cancer Research Fund may use resulting media coverage in its internal or external promotional activities.

Indicate any limitations or NONE.

Contact Information

Name (Parent or Guardian)*
Child's Name*
Child's date of birth*
This data is confidential and helps us offer age appropriate opportunities.
Date of diagnosis*
Address*
Consent*
Today's Date*
This field is for validation purposes and should be left unchanged.