Consent Form

 

Just One More Day for Love, Hope & a Cure
www.JustOneMoreDay.org
Just One More Day is a non profit organization dedicated to assist families effected by Diffuse Intrinsic Pontine Gliomas

 

Consent Form
The information provided will be used for our Featured Child, DIPG Children and possibly additional pages on JustOneMoreDay.org

 

Child’s Information
The information provided maybe used or shared on our website (www.JustOneMoreDay.org)

Name
Birth date
Names of parents & siblings
Diagnosis
Date of Diagnosis
Website
Treating Hospital
Treatment

Picture:  Please email an attach photo of child & family photo, if possible.
Any additional information you would like to share

 

Family Information
The following information is for contact use by Just One More Day administration only.

Parent(s) first & last name

_______________________________
Signature of parent (Sign or type name on form)
Address
Home phone number
Cell number
Email address

I hereby grant permission to Just One More Day to use the photographs and/or video of my son or daughter that I submit or the information which I provide in connection with the Just One More Day website or its publications.  
I acknowledge that my child has a brain tumor and I give permission to Just One More Day for Love, Hope & a Cure to post my child’s name, age, diagnosis, website, treating hospital, treatment, photo & any additional information that I provide.  I release and hold harmless Just One More Day for Love, Hope & a Cure harmless for such use.