Parent Information

Parent/Legal Guardian Name

Street Address

City, State, Zip

Email Address

Phone Number (000) 000-0000

Child's Information

Name

Age

Diagnosis

Current Status (ex. on treatment, etc.)

Hospital Information

Hospital Treated at:

Please email Blair Scroggs, the Public Relations Coordinator at bscroggs@acco.org if you have any problems or questions.

The next page is the interest form followed by the model consent form. By proceeding and inputting your name into the next form, you are agreeing to the form specifications.

Category Interest

Make a video and submit it to ACCO in one (or ALL) of the categories below! We are excited to start this project with you and look forward to your awesome videos!

Weather: Have you seen "Some Good News" the series? We want you to tell the "weather" where you are! Are you inside - tell us how the "weather" is inside! At the beach? Tell us about the salty air. The sky is the limit!

Sports: What sports are you playing in the hospital? Are you riding down the halls in wheelchairs or an IV pole? Are you zooming around in a motorized car? We want to see your creative sporting events!

ACCO Spot: How has ACCO helped you? Show your ACCO resources and how you play with them!

Kids Feature: This is the place to tell YOUR story! Tell us about your journey from your perspective!

Day in the Life feature: Heading to the hospital? Getting chemo or radiation? Have your parents follow you around with a camera and tell what a normal day is in the life of a childhood cancer warrior.

Inspiration Corner: Who inspires you? Have you met someone that helps you get through your treatments and journey? Tell us about them! What about your care team - do the doctors and nurses inspire you?

Advice: What's something you would tell another cancer patient? We want to showcase advice from kids FOR kids. This is your time to shine.

What category would YOU like to submit your video?

Deadline - September 20, 2020!

Remember, the earlier the better - submit your videos earlier for quicker turnaround in episodes!

Once you've submitted your interest form, Blair Scroggs will be getting in contact with you to get your video(s).

Social Media Consent Form

The dignity and privacy of our children and their families is a priority for the American Childhood Cancer Organization (ACCO) and their affiliates. If you choose not to have your child, their siblings or your family's photos taken at any ACCO events, it will not impact your ability to receive services. The photos and materials taken and used by ACCO and their affiliates are to promote our services to the community, share photos among other families within our organization and to advertise activities to the community.

Parent/Guardian Name

provide my consent and authorize the American Childhood Cancer Organization to use my child's photographs in promotional material for the organization. Some examples of promotional material where photographs might be use are newspapers, magazines, publications, advertisements/flyers, television, web sites or social media. Photographs will be the sole property of the photographer named below and the American Childhood Cancer Organization. I hereby release all claims and liability relating to social media.

In addition, I understand and agree to the following:

The photographs received by the ACCO remains the exclusive property of ACCO
My first name and/or child's first name, age, gender, and/or diagnosis may be named in connection with the public use of the photographs shared as ACCO deems appropriate.
My child's photographs may need to be modified slightly for use.
Any photographs of my child received by the ACCO are and will remain the exclusive property of ACCO.
By releasing my child's photographs, I cannot use these photos for anything but my own personal use and must consult with the ACCO for any additional uses, such as commercial and marketing purposes. Photographs may not be sent to other nonprofits or childhood cancer communities without permission from ACCO.

I understand and agree that ACCO may use such photographs with or without our name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content. I also acknowledge that by having a photograph publicized that my child may be identified as having been diagnosed with caner.

This authorization is continuous and will remain in effect until such authorization is rescinded. It is not necessary for ACCO to contact me prior to publishing this material in any literature, promotions or on the website. I relinquish all rights, title and interest in the photographs.

Please Fill Out Below

Parent/Guardian Name

Phone Number

Child Name

Diagnosis

Age

By adding my name below, I acknowledge the above.

Parent/Guardian Name

Date Signed

Parent/Guardian Name

Date Signed

Contact Information