Become a part of the Starlight Family!

Parent's First Name:

Parent's Last Name:

Child's First Name:

Child's Last Name:

Child's Birthday:

Child's Preferred Pronouns:

Child's Mailing Address (Where we can send your welcome package! Only families with a US address are eligible at this time.)

City

State

Zipcode

Name of child's hospital:

Please tell us about your child's diagnosis or health challenge.

How did you hear about Starlight?

Tell us about your child's favorite things to do!

Select the Starlight program(s) your child used:

Please share a specific story about how the Starlight program had a positive impact on you and your family (if your child has not experienced a Starlight program, please write N/A).

What did you and your child love most about the Starlight program? (if your child has not experienced a Starlight program, please write N/A).

Please upload any photos or videos of your child using our Starlight programs

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:

I would like to receive Starlight Family emails and updates (we won't sell your information)

Starlight Ambassadors

Starlight Ambassadors help us tell the story of what it's like to have a child living with a chronic condition that requires frequent trips to the hospital. Sharing your story will help raise public awareness about your child's diagnosis as well as Starlight and its programs. Not only is being a Starlight Ambassador a lot of fun, you'll also be helping deliver happiness to other seriously ill kids!

Please click here if you are interested in learning more about becoming a Starlight Ambassador!