Halloween Bead Giveaway!

Please fill out this form with your current postal mailing address so that we can send a fun holiday bead! The first 50 participants who submit a photo of their beads in the shape of a pumpkin, or a photo in your costumes with your beads, will receive a gift from Beads of Courage for participating! We hope you had some fun and enjoyed being creative with your beads! Thank you!

Name of parent or legal guardian Name of parent or legal guardian First Last
Postal mailing address Postal mailing address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email address
Child's name Child's name First Last
Child's Date of Birth Child's Date of Birth / MM / DD YYYY
Where does your child receive their beads? Please provide hospital/clinic name or put Beads in the Mail if applicable.
Beads of Courage Program? (i.e., hem/onc, cardiac, chronic conditions, etc.)
Please tell us how Beads of Courage has helped you/your child on their treatment journey:
For this giveaway please submit a picture of your beads in the shape of a pumpkin, or with your beads in your Halloween costume! Use your creativity! And of course we always love to see BOC members/siblings in the photos with their beads! If you would like, please upload 1-3 photos (or video). Additional photos/videos may be emailed to abby@beadsofcourage.org

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Attach Files
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If you uploaded photo/videos, please describe them, include the names of those pictured:
Were these photos taken by a commercial photographer?

Were these photos taken by a commercial photographer? Yes No
I hereby give Beads of Courage, Inc. permission to use this photo/video and content I have provided, in perpetuity, for any purpose deemed appropriate by Beads of Courage, Inc., including but not limited to: print materials; newsletters; signage; on the Beads of Courage website and social media accounts; for media coverage (television, blogs, newspaper, magazine, ezine, ebook, etc.); for educational purposes; for publicity benefiting Beads of Courage, Inc.

I hereby give Beads of Courage, Inc. permission to use this photo/video and content I have provided, in perpetuity, for any purpose deemed appropriate by Beads of Courage, Inc., including but not limited to: print materials; newsletters; signage; on the Beads of Courage website and social media accounts; for media coverage (television, blogs, newspaper, magazine, ezine, ebook, etc.); for educational purposes; for publicity benefiting Beads of Courage, Inc. Yes, I give permission No, I do not give permission
Date of form completion Date of form completion / MM / DD YYYY
ELECTRONIC SIGNATURE: By typing your full name in the box below, you are hereby waiving any right of compensation or ownership thereto.

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Full Name

I understand this is a legal representation of my signature.