Heartiversary Card Request

1

Name of person filling out form* This field is required.*Form must be submitted by a parent or guardian*

First Name

Last Name

2

E-mail* This field is required.

3

Name of Warrior* This field is required.

First Name

Last Name

4

Age of Warrior* This field is required.This program is designed for warriors 18 and under.

5

Address to mail the card to* This field is required.OPEN TO THOSE LIVING IN THE UNITED STATES ONLY AT THIS TIME

6

What is the date of their Heartiversary?

7

Photo of your warriorIf you would like to share a photo for us to give a shoutout to your warrior on their heartiversary on our monthly newsletter, please attach a photo.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

8

Consent* This field is required.Consent: By submitting this form, I grant CHD Tablet Talk Foundation a royalty-free, non-exclusive, perpetual license to use, reproduce, modify, and publish photographs, audio/video recordings, or other media in which I or my child (if under 18) appear or are heard. This permission includes use in whole or in part, with or without editing, in any format now known or developed in the future—including websites, social media, newsletters, print publications, and promotional or educational materials related to the Foundation’s mission. I understand that I or my child will not receive compensation for the use of this media, and that it may be used without further notice or approval. If the individual is a minor, I confirm that I am their parent or legal guardian and authorize this use on their behalf.

I agree

9

Parent/Guardian Signature

Clear