Child's Information









Place of Treatment




Child's Interests and Other Information



Child's Address

Unable to ship to P.O. Boxes or Hospitals





Parent's Information









No P.O. Boxes Please




For each sibling that you are submitting, please enter their first and last name.  We collect this information to insure that age appropriate joy items are sent.






























Please enter either your phone number or your email address. One of them is required. Thanks! 






No P.O. Boxes Please.





(OPTIONAL) Photo Release and Joy Mob 


If you would like to submit your courageous child's photo, please do so here. This is 100% optional. We use this information to honor our NEGU kids of the week and to JoyMob their support pages. 
The Jessie Rees Foundation will never share information about courageous kids and/or families unless authorized by a parent or legal guardian. However, many of our families are interested in having us sharing courageous kids stories and pictures on our website and social media platforms. If you are interested in  having us share your child's story and picture with our fans and followers, kindly complete the waiver below and upload some of your favorite pictures of your courageous kid.
LIKENESS RELEASE AND CONSENT FORM

I and/or any above-referenced child under 18 years of age on the date hereof (I, with any such child, collectively, the “Releasor”), hereby grant the JESSIE REES FOUNDATION (the “Foundation”) the Releasor’s irrevocable consent to distribute, publish, exhibit, digitize, broadcast, display, reproduce, photograph, videotape, or otherwise use the Releasor’s name, picture, portrait, likeness, voice, writings or biographical information (including, if applicable, disease diagnosis), and audiotape and/or videotape recordings, and sound or silent motion pictures of the Releasor in any manner or media whatsoever, whether now known or hereafter known (“Likeness”), anywhere in the world in perpetuity for any lawful purpose of the Foundation whatsoever, including without limitation, for editorial, educational, promotional, and advertising purposes, for the solicitation of contributions, as evidence in litigation, and for any other purpose in furtherance of the corporate purposes and objectives of the Foundation.  I affirm that I am the parent/legal guardian of any above-referenced child and that I have full authority to grant the releases, waivers, and consents herein, including rights in his or her Likeness.  I further agree that the foregoing provision shall apply to, without limitation, any Likeness (or any part thereof) provided by the Releasor to the Foundation, or uploaded by the Releasor to any Foundation media or social media platform, whether concurrent with the execution of this consent or at any time thereafter.  I also consent to the digital manipulation or distortion of any such Likeness, including, without restriction, any changes or alterations as to color, size, shape, perspective, context, foreground and background.  I further agree that the Foundation shall be the exclusive owner of all copyright and other rights in such Likeness.  Finally, I understand that the Releasor will not be compensated and agree that the Releasor will not seek at any time to receive any financial benefit or compensation in connection with such Likeness or use thereof.

I hereby, on behalf of the Releasor and the Releasor’s heirs, executors, administrators, assigns, and all legal guardians, WAIVE AND RELEASE ANY AND ALL RIGHTS, CLAIMS AND CAUSES OF ACTION OF ANY NATURE, EITHER IN LAW OR EQUITY, that the Releasor may have against the Foundation, its directors, officers, employees, agents, chapters, assignees, licensees, volunteers, and cooperating entities, and their respective representatives, heirs, executors, administrators, successors, and assigns (the “Released Parties”), whether known or unknown, fixed or contingent, which arise, or may arise hereafter, out of or are in any manner whatsoever, directly or indirectly, connected with or related to the Foundation’s use of the Likeness (collectively, the “Released Claims”).  I UNDERSTAND THAT BY EXECUTION OF THIS RELEASE THE RELEASOR IS AGREEING NOT TO SUE any or all of the Released Parties in connection with the Released Claims, and the Releasor will have no claim for any losses, injuries or damages arising from, in connection with, or related to the Released Claims, whether known or unknown on the date hereof.

By agreeing to this waiver, release, and consent, I certify that (i) I have read this document and fully understands it and the implications of signing this document, (ii) I am not relying on any statements or representations of any Released Party, orally or in writing, regarding the subject matter hereof, (iii) I acknowledge receipt of good and valuable consideration in exchange for this release, which may simply be the opportunity to represent the Foundation in its promotional and advertising materials as described above, and (iv) I understand that this document shall be binding upon me and any above-referenced child under 18 years of age on the date hereof, and their respective heirs, executors, administrators, assigns, and all legal guardians.




 


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