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True_Hero_Ambassador

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Question - Required - Birthdate:




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Question - Required - My child would be interested in:
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Question - Required - We share patient stories throughout the year in a variety of ways including newsletters, social media, personal attendance at events and more. Please select the areas that interest you:
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Question - Not Required - Please select the ways you are comfortable sharing your story:
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Terms and Conditions

I understand and agree to allow Peyton Manning Children's Hospital (PMCH) to use the information, photo and or video, I am submitting.

I understand that my information may be used for marketing, publicizing, or otherwise promoting the PMCH mission and that my information may be disseminated in any medium without geographic or time restriction.

I authorize the release of any information including health information contained in this submission and authorize the staff of PMCH to discuss this information with physicians and other staff, as necessary to verify the accuracy of the information.

I waive and release PMCH from any and all claims that I may have against PMCH or its offices, directors, employees, agents, or affiliates arising out of its use or dissemination of this information.

I also waive any right to royalties or other compensation for PMCH's use and dissemination of this information.

I assign all rights, including copyright, to the information to PMCH.

I represent and warrant that I have the authority to provide the information to PMCH and that no one else owns, or has superior rights to, this information.

I have read, fully understand, and voluntarily agree to be legally bound by this waiver, realease and authorization form.

I understand and agree that I may not use this site to conduct any activity that is illegal or that violates the rights of others. I represent and warrant that all information submitted is truthful and accurate.

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