Sharing Request Form

I grant my permission to The Samual Zion Foundation to use my story, videos, and/or other images provided by me or taken of me or taken of me during a Samual Zion Foundation event. Without further notification, the materials may be used for only furthering the Samual Zion Foundations mission to spread Congenital Diaphragmatic Hernia Awareness, and help enrich the lives of CDH patients and their families
This release includes the use in both internal and external publications such as: website feature articles, social media posts, donor letters, grant applications, and general publicity.
I release the Samual Zion Foundation and its employees from any claims, damages, or liability.
I am at least 18 years of age, or legal guardian, and competent to sign this release. I have read this release before signing and I understand the agreement and accept the terms.
I understand that this document will be submitted electronically. By inserting my name I agree to the terms and conditions.

I consent to my submitted data being collected and stored by Samual Zion Foundation.