CASK Media Release

Application
Yes

yesno
"Faces of CASK" Submission

Media submitted here is used for the "Faces of CASK" gallery, and throughout our website and other media platforms, as well as those of our affiliates, to spread awareness and accomplish all purposes of the foundation. You may choose to submit pictures only, or answer additional questions for the opportunity to have this person featured in a more detailed spotlight post. Not all spotlight entries are guaranteed for selection.
"In Memoriam" Submission

Media submitted here is used for the "In Memoriam" as well as the "Faces of CASK" galleries, and throughout our website and other media platforms, as well as those of our affiliates, to spread awareness and accomplish all purposes of the foundation. You may choose to submit pictures only, or to also include an epitaph and link to a memorial online.
4CASK Fundraising Team / Donation Page Application

Media submitted here is also used for the Faces of CASK gallery, and throughout our website and other media platforms to spread awareness and accomplish all purposes of the foundation. Please note: because this service is limited to those with confirmed CASK diagnoses, submissions for this service need to be associated with a CASK diagnosis that is validated in the CASK Registry.
Media Submission

Photos and videos submitted here are used throughout our website and other media platforms, as well as those of our affiliates, to spread awareness and accomplish all purposes of the foundation.
Please note: CASK services with photos feature those who are associated with a pathogenic CASK diagnosis in the CASK Registry. The CASK Registry form and photos of minors or vulnerable adults should be submitted only by their parent or other legal guardian.
Please indicate who is included in this release.*

Myself aloneMyself and a person with a CASK diagnosis.
Name of person with CASK diagnosis*

Given NameMiddle NameFamily / Surname
Their Date of Birth*

MonthDayYear
This is used to verify their diagnosis is listed in the CASK Registry
Their Date of Death*

MonthDayYear
Date
Your relationship to this person*
Which option would you prefer?*

submit pictures onlysubmit pictures and answer questions for spotlight post
Would you like to add a memorial link to the gallery, or just the photo?*

photo onlyphoto and link

Spotlight Questions

Tell us a bit more about the person with a CASK diagnosis.
What are some of this person's favorite things to have or do?
What do you feel has been the biggest challenge for helping this person?
What has been the most helpful resource or therapy you have found for this person?
Memorial

Here are some extra options you can add to their photo in the gallery.
Epitaph
In 140 characters or less, what is a quote or phrase that you feel best honors your loved one?
Link
Here, you can share a URL that we can link to (i.e. online obituary, news article, YouTube video, etc).
Is there anything else you would like to share about this person?

Fundraising Team / Custom Donation Page

We can set up a custom fundraising page in their honor as part of our "4CASK" giving campaign to support CASK Gene Foundation programs. We will customize this page with your loved one's photos, and you will receive your own unique QR code and "text to donate" keyword to make it easier for donors to find your team. From this page, donors can sign up online to become fundraisers for CASK Gene Foundation in honor of your loved one. You are not personally responsible for raising the funds or promoting the fundraiser, but as a team lead for this page you can express your preferences for the foundation programs that will be funded by the donations raised by your team.
Would you like to be set up with a 4CASK fundraising team page, in honor of this person?*

yesno
Team Name*
What name would you like for your team? (if the name is already taken, we'll reach out to you for alternatives)
Message to Donors*
Give 1 or 2 sentences to explain why you feel it's important - to you - for donors to support CASK Gene Foundation.

Team Donation Directives

Please let us know what your preferences would be for how to distribute your team's donations among our program areas. We require a minimum of 10% in the General Fund, and the total of all 4 must equal 100%.
Annual Fundraising Goal*
What would you like to set as the goal amount for your team to raise each year? (in US Dollars) NOTE: you are not personally responsible for raising this amount, and you can request this goal be changed later.
What percent of your team's donations would you like to direct to the General Fund? *
This fund may be used toward any of the foundations' program areas, as the board determines the greatest areas of need.
What percent of your team's donations would you like to direct to Research and Collaboration? *
This fund may be used for hosting internal and external CASK research studies, research grants or stipends, storage costs for the repositories (data, bio samples, EEGs, MRIs, etc), and for any services needed to support and coordinate all of the above.
What percent of your team's donations would you like to direct to Education and Awareness? *
This fund may be used toward any of the services and platforms used to improve education and awareness (website, mailers, instructional courses, conferences, awareness products given to families at no cost, etc.).
What percent of your team's donations would you like to direct to the Family Support? *
This fund may be used toward any of the services that provide direct support to CASK patients and their families, or to provide events, materials, and services that aim to improve their quality of life.
Percent of your goal that has been directed
The total must equal 100%. Please correct this before proceeding.

(example: General 25% + Research 25% + Education 25% + Family 25% = 100%)

About You

From here, you'll be guided through the process of uploading your pictures or videos and signing the release form.
Name of person submitting this form*

Given NameFamily / Surname
Email address*

Confirmation Emailexample@example.com

Media Release Form

You will have the opportunity to preview this form, completed with your data entered, before you sign and submit your files. Please make sure to complete all these next steps and press the "SUBMIT" button, or we will not receive your files.
Date

MonthDayYear
Date

Preferred Photo
Please use this field to submit your preferred photo*

More media files can be submitted on the next page.
Cancelof

File Upload(s)
If you would like to send more files, you can use this page to upload more pictures and videos (optional).
Please use this field to submit up to 4 media files.

Cancelof

Consent for Use of Personal Identifiers

Note: If this consent is granted, there is no guarantee that the media will appear with these personal identifiers.

I authorize my media to appear with: *

	Yes	No
my first name
my general location (i.e. state and/or country)

I authorize my media to appear with: *

	Yes	No
the first name of the person with a CASK diagnosis
their general location (i.e. state and/or country)

Signature
Please indicate which signature option you prefer:*

Electronic Signature - I consent to signing electronically, for immediate effect.Print and Sign - I understand that CGF will not use my media until I have returned this form with signature.

Signature
Click on the preview button below, if you would like to review your completed form prior to signing.
Signed*

Clear
Please use your mouse or touch screen to sign.

I am ready to submit my digital media, but I acknowledge that - because I chose to sign physically - my images will not be accepted or used until I physically sign and submit the PDF version of this form. I will email a scan to front.office@caskgene.org, or mail a hard copy to CASK Gene Foundation at 1830 N 1120 W, Provo UT 84604.*

Acknowledged
To access and print the PDF form, click on "Preview" below. After printing, please return to this screen by clicking on the "Back to Form" button, so that you can submit your digital images.
Should be Empty:

"Faces of CASK" Submission

"In Memoriam" Submission

4CASK Fundraising Team / Donation Page Application

Media Submission

Spotlight Questions

Memorial

Fundraising Team / Custom Donation Page

Team Donation Directives

About You

Media Release Form

Preferred Photo

File Upload(s)

Consent for Use of Personal Identifiers

Signature

Signature