Starlight logo

Starlight Story and Publicity Consent and Release

Starlight Children's Foundation (“Starlight”) 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 the experiences they’ve had 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 is always sought from patients or their families or guardians to provide names, photos and information about hospitalization and treatment. 

I hereby agree to participate in the event and 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, reuse and republish my name, image, personal characteristics, photographs, videos, essays, personal stories, biographical materials, 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 and 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 the foregoing and fully understand the contents thereof. 


mm/dd/yyyy

You will be asked for your E-signature on the following page. 
. If medically necessary, I hereby authorize appropriate authorities to offer emergency medical treatment. I have read the foregoing and fully understand the contents thereof.