SGS Photograph Consent

UK registered charity, number 1186327

AUTHORIZATION FOR USE OF INFORMATION AND PHOTOGRAPHS

The consent form below is available for you to complete to let the SGS Foundation know if you give permission for us to use information and/or photographs & images of your child on future SGS Foundation publications.

Name (Full Legal Name):*

Address*

Street Address

Street Address Line 2

CityState/Province/County

Zip/Postal CodeCountry

Email*

example@example.com

Phone Number*

Please Enter a Valid Phone Number(Including Country Code)

The Schinzel-Giedion Syndrome Foundation appreciates the support of families and caregivers willing to share their experiences with Schinzel-Giedion Syndrome (SGS). Your stories help raise awareness about SGS, the Foundation’s mission and rare diseases.

We value your privacy and confidentiality. By providing your information, photographs, and videos, you're granting permission for us to use them in various materials such as publications, websites, social media, videos, brochures related to the Schinzel-Giedion Syndrome Foundation. When showing a child's face, we will only include their first name, age, and country of residence.

Please indicate your permission for each separate item by ticking the appropriate box (you do not have to agree to all):*

I give permission for the Schinzel-Giedion Syndrome Foundation to share and use information about my/my child’s diagnosis, treatment, and experiences in its materials (such as publications, websites, social media, videos, and brochures).I give permission for the Schinzel-Giedion Syndrome Foundation to use photographs/images of myself/my child in its materials (such as publications, websites, social media, videos, and brochures).I give permission for the Schinzel-Giedion Syndrome Foundation to allow partner organizations and businesses that it works with to further the Foundation’s mission, to create media content featuring myself/my child's experience with SGS.

If any of the permissions above are given, I hereby release and waive all claims to compensation and rights regarding such use and/or publication

I understand that:

This authorization is voluntary.
If I don't sign this authorization, the Schinzel-Giedion Syndrome Foundation won't disclose the requested information/photographs/videos.
This authorization doesn't expire.
I can revoke/withdraw this authorization at any time by making a written request to the Schinzel-Giedion Syndrome Foundation via email or letter.

I am the:*

Parent with parental rights

Representative's Signature*

Date

Image File Upload*