Referral Form for CHD Tablet Talk

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Name of individual filling out form
First Name
Last Name
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Name of RecipientWe keep all names of recipients anonymous when sharing
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Email address
example@example.com
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Please share with us your child's experience with CHD Tablet Talk
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Ok
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Please include an image of the child for us to share.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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ConsentI hereby grant CHD Tablet Talk, royalty-free, non-exclusive, perpetual (for the duration of the applicable copyright) license to reproduce the photograph(s), audio or video media, and to incorporate the media into one or more Collective Works (including but not limited to newsletters, websites, and any other media or publications as CHD Tablet Talk deems appropriate for promoting program activities and to reproduce the media as incorporated in the Collective Works. The above rights may be exercised in all media and formats whether now known or hereafter devised. The above rights include the right to make such modifications, including but not limited to cropping or altering the photograph(s) as are technically necessary to exercise the rights in other media and formats.
I consent to the statement above.
Should be Empty: