SIOD Superhero Form

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SIOD Superhero Form

Please complete the form below to be featured on our website & social media platforms. When the form is complete please send 3 or more images to stacy@kruznforakure.com.

Email *

Parent Name *

SIOD Patient Name *

SIOD Patient Birthday *

YYYY

Address (only state & country will be publicized) *

How old was your child when they were diagnosed with SIOD? *

What were your thoughts when you FIRST learned that your child was diagnosed with SIOD? *

Tell us briefly about the medical complications that have occurred because of SIOD *

What has your child's treatment plan looked like? *

What challenges does your family face because of SIOD? *

What would a cure mean to you and your child? *

Give us some information about your SIOD patient (hobbies, favorite color, their personality) *

Are you open to help spread awareness and possibly fundraising in your area? *

Yes

Other:

Release of information: I grant permission to Kruzn for a Kure Foundation hereinafter known as the “Media” to use my image (photographs and/or video) and survey responses in Media publications. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. *

I agree

I disagree

Send me a copy of my responses.

Submit

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