Referral Form for CHD Tablet Talk

1

Name of individual filling out form

First Name

Last Name

2

Name of RecipientWe keep all names of recipients anonymous when sharing

3

Email address

example@example.com

4

Please share with us your child's/facility's experience with CHD Tablet Talk and how it was helpful to the child during their stay.

5

If you have a photo of your child using the Tablet that we are able to share, please include that hereBy including your image you agree to the following: I 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.

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