Name of child's hospital

Please give us some background about your child's diagnosis, health challenges, and hospital experience.

How did you hear about Starlight?

Select the Starlight program(s) your child used:

Starlight Hospital GownsStarlight Gaming/Fun Center/Nintendo Switch Gaming StationStarlight Virtual RealityStarlight Radio Flyer WagonStarlight Toy Deliveries - my child received a toy or book donated by StarlightStarlight Spaces - a hospital room donated by StarlightMy child has not received Starlight programs.

Please share if/how Starlight programs changed the hospital experience and positively impacted you and your child.

Hospitalization and treatments can produce stress and anxiety in patients. What difference did you observe in your child after using Starlight programs? Did they help reduce pain, keep your child motivated or calm, or help them feel less anxious?

Would you be open to sharing your story to help raise awareness of pediatric illness, your child's diagnosis, and the value of Starlight's programs with our donors, hospital partners, and other families in our network?

YesNo

If you have a social media profile where you share updates about your child and you would like us to follow you, please share those handles below.

Instagram, Facebook: @starlightchildrensfoundation | X (twitter): @StarlightUS

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:

I would like to receive Starlight Family email updates and be granted access to the Family Resource Portal (we won't sell your information)

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