Card Of Encouragement Request

1

Name of person filling out form* This field is required.

First Name

Last Name

2

E-mail* This field is required.

3

Name of Warrior* This field is required.

First Name

Last Name

4

Address to mail the card to* This field is required.

5

Please share a little about your warrior / what surgery(s) they had* This field is required.Age, age that they had the surgery, what their interests are, etc. This gives us some ideas of what to write in their card. We will not share this information.

6

What type of card are you looking for* This field is required.

Annual Heartiversary Card

Get well soon card

General card of encouragement

7

If you selected Heartiversary, what is the date of their Heartiversary?

8

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

9

Consent* This field is required. 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.

I agree