Beads of Courage Photo/Video Submission and Release Form

Please use this form to upload up to 5 photos to share with us at BOC. Thank you!

Parent/Guardian Name (if submitting BOC member or sibling photos). Otherwise enter name of self-adult making submission. Parent/Guardian Name (if submitting BOC member or sibling photos). Otherwise enter name of self-adult making submission. First Last
Email
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
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.)
Optional: Child's medical condition
Beads of Courage is celebrating our 20th anniversary in 2023! - Please tell us what you love or value about Beads of Courage for yourself, your child, and/or your family:
Please upload 1-5 photos (or video). We love to see photos of BOC members/siblings with their beads! Additional photos/videos may be emailed to beth@beadsofcourage.org

Attach Files
Optional: Please describe the photos/videos you uploaded, 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 No
Date of Photo Release Date of Photo Release / MM / DD YYYY
ELECTRONIC SIGNATURE: By placing your signature in the box below, you are hereby waiving any right of compensation or ownership thereto.