Online Photo and Story Release for Starlight Children’s Foundation

Starlight Children’s Foundation (“Starlight”) is grateful to patients, families, donors and other Starlight community members who are willing to share their stories and photos. Information about treatment a patient has received, the people the patient has met, and his or her experiences can prove enormously helpful to understanding the positive impact of Starlight’s 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 is always sought from patients or their parents or guardians to provide names, photos, and information about hospitalization and treatment.

By signing this document, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, and without any further consideration due from Starlight or any third party to me:

  • If signing the consent form for a minor(s):

  • If signing the consent form for yourself: