Smiley Kit Request Form

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Parents/Guardian/Referrer fill up this form to request a smiley bag from Smiles From Sean. Information gathered and in this form is used solely for personalization and shipment of the kit to the recipient.

Email *

Child's name: *

Address
(Street/City/State/Zip Code) *

Age /Gender

Type of Illness

Relationship to the child

Referrer's Contact Information (phone/email) *

AUTHORIZATION

By filling up this form I agree and understand that Smiles from Sean shall have all the legal rights to information I provided in here and that I voluntarily give up my rights to these organization and will not receive any payment or compensation for the same now and the future. I understand that the photography/recording/interview maybe used to showcase Smiles From Sean mission and could appear to Smiles from Sean social media channels, website or elsewhere on the internet. I hereby released and discharge Smiles from Sean and its team members from any claims, liability or results caused by use of such photography/recording/interview of me as provided herein.
Please sign by writing your name and date below.

Name and Date: *

A copy of your responses will be emailed to the address you provided.

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