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1
Registration Information
Patient Nameyour full name
Patient Surname
Gender
Birthdate
Hospital patient is/was in and ward
School
Parent/Guardian Information
Parent/Guardian Name
Parent/Guardian Surname
Parent/Guardian Name
Parent/Guardian Surname
Phone Numberyour full name
Mobile Number
Sibling Information
Siblings
Sibling Name
Age
Gender
Sibling Name
Age
Gender
Sibling Name
Age
Gender
Sibling Name
Age
Gender
Eventyour full name
Name ticket 1your full name
Age
Name ticket 2your full name
Age
Name ticket 3your full name
Age
Name ticket 4your full name
Age
Name ticket 5your full name
Age
Name ticket 6your full name
Age
Wheelchair
Consent for photography, interviews and filming
I agree

We would like to interview, photograph or film patients, their parents and relatives in order to promote the work of Spread a Smile. This form allows us to make sure that we have accurate information about your child and records the fact that you have agreed to your child taking part in the interview or photo shoot. Interviews, photograph shoots and filming are only undertaken with your permission. If you have any questions or concerns about what the materials will be used for please contact us at [email protected]

Your Address
Street Address
Apt, Suite, Bldg.
City
State / Province / Region
Postal / Zip Code

I give permission for Spread a Smile to use these photographs/film for marketing purposes on their website [www.spreadasmile.org], other Spread a Smile sites (such as Facebook, Twitter, Instagram and YouTube) and in Spread a Smile publications.

eSignatureyour full name
Commentsmore details
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Message
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