Share Your Holiday Story!
Child's first name
Child's last name:
Has your child experienced an in-patient stay in the hospital over the holidays? Please describe your child's medical journey including the diagnosis, length of stay, and treatment outcomes.
Please be as detailed as you'd like!
Share and describe as much as you remember about your experience in the hospital over the holidays. What feelings do you and your child remember experiencing during this time? Please include any specific moments that left an impact.
Please be as detailed as you'd like!
What Starlight programs did you receive and how did they provide comfort and happiness to your child during this time? Why do you think having access to those resources was important?
Please be as detailed as you'd like!
Please share anything else you would want donors to know about your experience as a parent of a hospitalized child, especially during special occasions like the holidays. Your words will help our donors understand the journey of Starlight Families like yours and the difference their support can make.
Please be as detailed as you'd like!
At which hospital did your child spend the holidays?
Please upload any photos or videos related to your child's hospital experience with Starlight programs during the holiday season.
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: