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Let your CHD Story be Heard!
In order to be featured during our Heart Month campaign, please fill out and submit this form.
7
Questions
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1
Name of person filling out form
First Name
Last Name
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2
Name of individual with CHD
If different from the person filling out the form - for example, parents filling out the form of their child.
First Name
Last Name
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3
Email
example@example.com
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4
What is the individual's CHD diagnosis?
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5
Please share your families story...
This can include past or upcoming surgeries, likes, dislikes, activities or favorite subjects in school, whatever your heart desires.
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6
Please submit a photo you would like featured
For example, a picture of you/the individual with CHD in the hospital, at a doctor's appointment, a scar, etc. Please do not submit more than two photos.
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: 10.6MB
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7
Consent
I hereby grant Conquering CHD, 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 Conquering CHD 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 consent to the Media Release and Copyright License below
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