Story Submissions Form

Parent's Name*

First NameLast Name

Child's Name*

First Name OnlyNot Applicable

Cleft Type?*

State Child Lives In*

I am submitting: (select all that apply)*

Single photo for LCN awareness and marketingWritten journeyMultiple photos for journey page and LCN awareness and marketingVideo journey

Upload Photo(s)

Upload Written Journey

Upload Video

I hereby grant the releasee permission to use my child's written journey, photograph(s), video, first name, state, and laryngeal cleft type in any of the following:

Release of Photographs/Video in*

Web-based or print-based publications, including website, social media accounts, brochures, and more.

I hereby affirm that such release to the releasee does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.

I understand and agree that photographs/video/story in the possession of the releasee shall become the property of the releasee. The use and publication of the photographs/video/story however, shall conform to my rights as a subject of said materials.

I hereby waive my right to inspect or approve the photographs/video/story by which my likeness appears.

I hereby hold harmless, release, and forever discharge the Laryngeal Cleft Network from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Age of Consent*

I am a minor and represented by my parent/guardian

I declare true my age of consent, and in case I am under the age of such consenting age, I have obtained the required consent from my parents/guardians as evidenced by the signatures below:

First Name of Child Subject of Photograph/Journey/Video (Note: this name will be published)*

Type of Laryngeal Cleft: 1, 2, 3, or 4 (Note: the cleft type will be published)*

Full Name of Parent/Guardian of Child Subject of Photograph*

Parent's Phone Number*

Parent's Email Address*

Signature of Parent/Guardian*

Date SIgned

Date