First Name

Last Name:

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Please share if/how Starlight programs changed the hospital experience for your family, or how our mission may have impacted you in other ways. By submitting a story of yourself, your child, your company, your patient, etc., you are helping us share the impact of Starlight with our community.

Does your story speak about a child's experience? If so, please provide their name.

Child's First Name:

Please upload any photos or videos related to your experience with Starlight.

If you're uploading photos and/or give permission for us to share your story, please check the box below to sign our Publicity Consent Form

Starlight Children's Foundation is grateful to patients and families who are willing to share their stories. Information about treatment a patient has received, the people they've met and their experiences can prove enormously helpful to understanding the positive impact of Starlight programs. At the same time, the privacy of patients, families and their visitors, as well as the confidentiality of medical and related information, are among our highest priorities. Therefore, permission always is sought from patients or their families or guardians to provide names, photos and information about hospitalization and treatment. By signing this document, I grant Starlight permission regarding the following: I grant Starlight and any of Starlight’s agents, corporate partners, assignees, or licensees (“Released Parties”) the irrevocable, unconditional, and unrestricted right (but not the obligation) to use any photographs, videos, my name, image, personal characteristics, essays, personal story, biographical material, artwork, voice and/or likeness (“Materials”) in any promotions, publicity, and advertising utilizing the Materials respecting the Released Parties. I acknowledge that I will not receive any compensation for any use of the Materials. I acknowledge that Starlight shall own all right, title, and interest (including, without limitation, the copyright) in such Materials. I waive and release all Released Parties from any and all claims or demands. I may now, or in the future, have, arising out of, or in connection with, this release agreement or the Materials including, without limitation, any claims respecting invasion of privacy, copyright infringement, right of publicity, defamation and any other personal and/or property rights.

I have read and understood this consent and release.

Name of person signing this consent form:

First and Last Name

Relationship to child:

Phone Number:

Email: