Children’s Cancer Research Fund Authorization for Photography, Filming or Interviewing & Photo Sharing 2024 Release Form "*" indicates required fields 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. The foregoing consent is subject to the following LIMITATIONS:*Indicate any limitations or NONE.Contact InformationName (Parent or Guardian)* First Last Child's Name* First Last Child's date of birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This data is confidential and helps us offer age appropriate opportunities.Child's type of cancer*Date of diagnosis*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code For minors: I, the undersigned hereby state that I am the parent or legal guardian of the child and do hereby consent and give my permission to this Agreement. I have read the above authorization, release and agreement and am fully aware of all that it states or implies. Today's Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature*CommentsThis field is for validation purposes and should be left unchanged.
