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class="section inline group"> <div class="oneField field-container-D " id="tfa_1-D"> <label id="tfa_1-L" class="label preField reqMark" for="tfa_1">Parent/Legal Guardian Name </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_1" name="tfa_1" value="" title="Parent/Legal Guardian Name " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_3-D"> <label id="tfa_3-L" class="label preField " for="tfa_3">Parent/Legal Guardian Name </label><br><div class="inputWrapper"><input type="text" id="tfa_3" name="tfa_3" value="" title="Parent/Legal Guardian Name " class=""></div> </div> </div> <div id="tfa_19" class="section inline group"> <div class="oneField field-container-D " id="tfa_17-D"> <label id="tfa_17-L" class="label preField reqMark" for="tfa_17">Street Address </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_17" name="tfa_17" value="" title="Street Address " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_18-D"> <label id="tfa_18-L" class="label preField reqMark" for="tfa_18">City, State, Zip</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_18" name="tfa_18" value="" title="City, State, Zip" class="required"></div> </div> </div> <div id="tfa_23" class="section inline group"> <div class="oneField field-container-D " id="tfa_20-D"> <label id="tfa_20-L" class="label preField reqMark" for="tfa_20">Email Address </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_20" name="tfa_20" value="" title="Email Address " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_22-D"> <label id="tfa_22-L" class="label preField " for="tfa_22">Email Address </label><br><div class="inputWrapper"><input type="text" id="tfa_22" name="tfa_22" value="" title="Email Address " class=""></div> </div> </div> <div id="tfa_50" class="section inline group"> <div class="oneField field-container-D " id="tfa_25-D"> <label id="tfa_25-L" class="label preField reqMark" for="tfa_25">Phone Number (000) 000-0000</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_25" name="tfa_25" value="" title="Phone Number (000) 000-0000" class="required"></div> </div> <div class="oneField field-container-D " id="tfa_49-D"> <label id="tfa_49-L" class="label preField " for="tfa_49">Phone Number (000) 000-0000</label><br><div class="inputWrapper"><input type="text" id="tfa_49" name="tfa_49" value="" title="Phone Number (000) 000-0000" class=""></div> </div> </div> </fieldset> <fieldset id="tfa_26" class="section"> <legend id="tfa_26-L">Child's Information </legend> <div id="tfa_30" class="section inline group"> <div class="oneField field-container-D " id="tfa_27-D"> <label id="tfa_27-L" class="label preField reqMark" for="tfa_27">Name </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_27" name="tfa_27" value="" title="Name " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_29-D"> <label id="tfa_29-L" class="label preField reqMark" for="tfa_29">Age </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_29" name="tfa_29" value="" title="Age " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_32-D"> <label id="tfa_32-L" class="label preField reqMark" for="tfa_32">Diagnosis  </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_32" name="tfa_32" value="" title="Diagnosis " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_62-D"> <label id="tfa_62-L" class="label preField reqMark" for="tfa_62">Current Status (ex. on treatment, etc.)  </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_62" name="tfa_62" value="" title="Current Status (ex. on treatment, etc.) " class="required"></div> </div> </div> </fieldset> <fieldset id="tfa_35" class="section"> <legend id="tfa_35-L">Hospital Information </legend> <div class="oneField field-container-D " id="tfa_34-D"> <label id="tfa_34-L" class="label preField reqMark" for="tfa_34">Hospital Treated at:</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_34" name="tfa_34" value="" title="Hospital Treated at:" class="required"></div> </div> </fieldset> <div class="htmlSection" id="tfa_52"><div class="htmlContent" id="tfa_52-HTML"><div style="text-align: center;"><span style="caret-color: initial; font-style: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;">Please email Blair Scroggs, the Public Relations Coordinator at bscroggs@acco.org if you have any problems or questions. </span></div></div></div> <div class="htmlSection" id="tfa_63"><div class="htmlContent" id="tfa_63-HTML"><h4>The next page is the interest form followed by the model consent form. <span style="caret-color: initial; font-style: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;">By proceeding and inputting your name into the next form, you are agreeing to the form specifications.</span></h4></div></div> </div></div> <div class="wfPage" id="wfPgIndex-2"><div class="section pageSection" id="tfa_115"> <div class="htmlSection" id="tfa_134"><div class="htmlContent" id="tfa_134-HTML"><img src="//www.tfaforms.com/forms/get_image/156274/yMLpXYzA7J8RBHa5bxNjGRa8g0AWDFppEqmsbcBLkAk4mCS0WBsSzsQICJCj8HAw-ScreenShot2020-07-24at9.11.54AM.png" alt="." style="max-width: 100%;"></div></div> <div class="htmlSection" id="tfa_116"><div class="htmlContent" id="tfa_116-HTML"><div style="text-align: center;"><b style="caret-color: initial; font-style: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;">Category Interest </b></div><br>Make a video and submit it to ACCO in one (or ALL) of the categories below! We are excited to start this project with you and look forward to your awesome videos! <br><br><b>Weather</b>: Have you seen "<a target="_blank" href="https://youtu.be/Oob-iUDsnkY">Some Good News</a>" the series? We want you to tell the "weather" where you are! Are you inside - tell us how the "weather" is inside! At the beach? Tell us about the salty air. The sky is the limit! <br><br><b>Sports</b>: What sports are you playing in the hospital? Are you riding down the halls in wheelchairs or an IV pole? Are you zooming around in a motorized car? We want to see your creative sporting events!<br><br><b>ACCO Spot</b>: How has ACCO helped you? Show your ACCO resources and how you play with them! <br><br><b>Kids Feature</b>: This is the place to tell YOUR story! Tell us about your journey from your perspective! <br><br><b>Day in the Life feature</b>: Heading to the hospital? Getting chemo or radiation? Have your parents follow you around with a camera and tell what a normal day is in the life of a childhood cancer warrior.<br><br><b>Inspiration Corner</b>: Who inspires you? Have you met someone that helps you get through your treatments and journey? Tell us about them! What about your care team - do the doctors and nurses inspire you? <br><br><b>Advice</b>: What's something you would tell another cancer patient? We want to showcase advice from kids FOR kids. This is your time to shine.    <br><br><div style="text-align: center;"><b>What category would YOU like to submit your video?</b><span style="caret-color: initial; font-style: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;"> </span></div><div style="text-align: center;"><span style="caret-color: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;"><i><u>Deadline - September 20, 2020!</u></i><span style="font-style: initial;"> </span></span></div><div style="text-align: center;"><span style="caret-color: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;"><span style="font-style: initial;">Remember, the earlier the better - submit your videos earlier for quicker turnaround in episodes!  </span></span></div><div style="text-align: center;"><span style="caret-color: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;"><span style="font-style: initial;"><br></span></span></div><div style="text-align: center;"><span style="caret-color: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;"><span style="font-style: initial;">Once you've submitted your interest form, Blair Scroggs will be getting in contact with you to get your video(s).  </span></span></div></div></div> <div class="oneField field-container-D " id="tfa_125-D" role="group" aria-labelledby="tfa_125-L" data-tfa-labelledby="-L tfa_125-L"> <label id="tfa_125-L" class="label preField reqMark" data-tfa-check-label-for="tfa_125" aria-label="Choose the categories you're interested in: 聽 required">Choose the categories you're interested in:</label><br><div class="inputWrapper"><span id="tfa_125" class="choices vertical required"><span class="oneChoice"><input type="checkbox" value="tfa_126" class="" id="tfa_126" name="tfa_126" aria-labelledby="tfa_126-L" data-tfa-labelledby="tfa_125-L tfa_126-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_126-L" for="tfa_126"><span class="input-checkbox-faux"></span>Weather </label></span><span class="oneChoice"><input type="checkbox" value="tfa_127" class="" id="tfa_127" name="tfa_127" aria-labelledby="tfa_127-L" data-tfa-labelledby="tfa_125-L tfa_127-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_127-L" for="tfa_127"><span class="input-checkbox-faux"></span>Sports </label></span><span class="oneChoice"><input type="checkbox" value="tfa_128" class="" id="tfa_128" name="tfa_128" aria-labelledby="tfa_128-L" data-tfa-labelledby="tfa_125-L tfa_128-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_128-L" for="tfa_128"><span class="input-checkbox-faux"></span>ACCO Spot </label></span><span class="oneChoice"><input type="checkbox" value="tfa_129" class="" id="tfa_129" name="tfa_129" aria-labelledby="tfa_129-L" data-tfa-labelledby="tfa_125-L tfa_129-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_129-L" for="tfa_129"><span class="input-checkbox-faux"></span>Kids Feature </label></span><span class="oneChoice"><input type="checkbox" value="tfa_130" class="" id="tfa_130" name="tfa_130" aria-labelledby="tfa_130-L" data-tfa-labelledby="tfa_125-L tfa_130-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_130-L" for="tfa_130"><span class="input-checkbox-faux"></span>Day in the Life Feature </label></span><span class="oneChoice"><input type="checkbox" value="tfa_131" class="" id="tfa_131" name="tfa_131" aria-labelledby="tfa_131-L" data-tfa-labelledby="tfa_125-L tfa_131-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_131-L" for="tfa_131"><span class="input-checkbox-faux"></span>Inspiration Corner </label></span><span class="oneChoice"><input type="checkbox" value="tfa_132" class="" id="tfa_132" name="tfa_132" aria-labelledby="tfa_132-L" data-tfa-labelledby="tfa_125-L tfa_132-L" data-tfa-parent-id="tfa_125"><label class="label postField" id="tfa_132-L" for="tfa_132"><span class="input-checkbox-faux"></span>Advice </label></span></span></div> </div> </div></div> <div class="wfPage" id="wfPgIndex-3"><div class="section pageSection" id="tfa_65"> <div class="htmlSection" id="tfa_66"><div class="htmlContent" id="tfa_66-HTML"><img src="//www.tfaforms.com/forms/get_image/156274/sldmz0t2JxPNnSnS9beEuP7hGpMTkGmP69xPLdas3zbLEZHL2ikUZpqBxuwUCRC5-BYQjt9ME.png" alt="ACCO logo" style="max-width: 100%;"></div></div> <div class="htmlSection" id="tfa_67"><div class="htmlContent" id="tfa_67-HTML"><div style="text-align: center;"><b style="caret-color: initial; font-style: initial; font-variant-caps: initial; letter-spacing: initial; orphans: initial; text-align: initial; text-indent: initial; text-transform: initial; white-space: initial; widows: initial; word-spacing: initial; -webkit-text-decorations-in-effect: initial; -webkit-text-fill-color: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-color: initial; -webkit-text-stroke-width: initial;">Social Media Consent Form</b></div></div></div> <div class="htmlSection" id="tfa_69"><div class="htmlContent" id="tfa_69-HTML">The dignity and privacy of our children and their families is a priority for the American Childhood Cancer Organization (ACCO) and their affiliates.  If you choose not to have your child, their siblings or your family's photos taken at any ACCO events, it will not impact your ability to receive services.  The photos and materials taken and used by ACCO and their affiliates are to promote our services to the community, share photos among other families within our organization and to advertise activities to the community. </div></div> <div id="tfa_72" class="section inline group"> <div class="oneField field-container-D " id="tfa_70-D"> <label id="tfa_70-L" class="label preField reqMark" for="tfa_70">Parent/Guardian Name </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_70" name="tfa_70" value="" title="Parent/Guardian Name " class="required"></div> </div> <div class="htmlSection" id="tfa_71"><div class="htmlContent" id="tfa_71-HTML">provide my consent and authorize the American Childhood Cancer Organization to use my child's photographs in promotional material for the organization. Some examples of promotional material where photographs might be use are newspapers, magazines, publications, advertisements/flyers, television, web sites or social media. Photographs will be the sole property of the photographer named below and the American Childhood Cancer Organization. I hereby release all claims and liability relating to social media. </div></div> </div> <div class="htmlSection" id="tfa_73"><div class="htmlContent" id="tfa_73-HTML"><h4><span style="font-weight: normal;">In addition, I understand and agree to the following: </span></h4></div></div> <div class="htmlSection" id="tfa_74"><div class="htmlContent" id="tfa_74-HTML"><ul><li><span style="orphans: initial; text-align: initial; text-indent: initial; widows: initial; -webkit-text-fill-color: initial; -webkit-text-stroke-color: initial;"><span style="caret-color: initial; font-style: initial; font-variant-caps: initial; letter-spacing: initial; text-transform: initial; white-space: initial; word-spacing: initial; -webkit-text-size-adjust: initial; -webkit-text-stroke-width: initial;">The photographs received by the ACCO remains the exclusive </span>property of ACCO </span></li><li><span style="orphans: initial; text-align: initial; text-indent: initial; widows: initial; -webkit-text-fill-color: initial; -webkit-text-stroke-color: initial;">My first name and/or child's first name, age, gender, and/or diagnosis may be named in connection with the public use of the photographs shared as ACCO deems appropriate.</span></li><li><span style="orphans: initial; text-align: initial; text-indent: initial; widows: initial; -webkit-text-fill-color: initial; -webkit-text-stroke-color: initial;">My child's photographs may need to be modified slightly for use. </span></li><li><span style="orphans: initial; text-align: initial; text-indent: initial; widows: initial; -webkit-text-fill-color: initial; -webkit-text-stroke-color: initial;">Any photographs of my child received by the ACCO are and will remain the exclusive property of ACCO. </span></li><li><span style="orphans: initial; text-align: initial; text-indent: initial; widows: initial; -webkit-text-fill-color: initial; -webkit-text-stroke-color: initial;">By releasing my child's photographs, I cannot use these photos for anything but my own personal use and must consult with the ACCO for any additional uses, such as commercial and marketing purposes. Photographs may not be sent to other nonprofits or childhood cancer communities without permission from ACCO.</span></li></ul></div></div> <div class="htmlSection" id="tfa_75"><div class="htmlContent" id="tfa_75-HTML">I understand and agree that ACCO may use such photographs <b>with or without our name and for any lawful purpose</b>, including for example such purposes as publicity, illustration, advertising and web content. I also acknowledge that by having a photograph publicized that my child may be identified as having been diagnosed with caner. <br><br>This authorization is continuous and will remain in effect until such authorization is rescinded.  It is not necessary for ACCO to contact me prior to publishing this material in any literature, promotions or on the website. I relinquish all rights, title and interest in the photographs. </div></div> <fieldset id="tfa_77" class="section"> <legend id="tfa_77-L">Please Fill Out Below</legend> <div id="tfa_81" class="section inline group"> <div class="oneField field-container-D " id="tfa_78-D"> <label id="tfa_78-L" class="label preField reqMark" for="tfa_78">Parent/Guardian Name </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_78" name="tfa_78" value="" title="Parent/Guardian Name " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_80-D"> <label id="tfa_80-L" class="label preField reqMark" for="tfa_80">Phone Number </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_80" name="tfa_80" value="" title="Phone Number " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_83-D"> <label id="tfa_83-L" class="label preField reqMark" for="tfa_83">Child Name</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_83" name="tfa_83" value="" title="Child Name" class="required"></div> </div> <div class="oneField field-container-D " id="tfa_87-D"> <label id="tfa_87-L" class="label preField reqMark" for="tfa_87">Diagnosis </label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_87" name="tfa_87" value="" title="Diagnosis " class="required"></div> </div> <div class="oneField field-container-D " id="tfa_85-D"> <label id="tfa_85-L" class="label preField reqMark" for="tfa_85">Age</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_85" name="tfa_85" value="" title="Age" class="required"></div> </div> </div> </fieldset> <div class="htmlSection" id="tfa_107"><div class="htmlContent" id="tfa_107-HTML"><h4>By adding my name below, I acknowledge the above. </h4></div></div> <div id="tfa_110" class="section inline group"> <div class="oneField field-container-D " id="tfa_108-D"> <label id="tfa_108-L" class="label preField reqMark" for="tfa_108">Parent/Guardian Name</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_108" name="tfa_108" value="" title="Parent/Guardian Name" class="required"></div> </div> <div class="oneField field-container-D " id="tfa_112-D"> <label id="tfa_112-L" class="label preField reqMark" for="tfa_112">Date Signed</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_112" name="tfa_112" value="" title="Date Signed" class="required"></div> </div> <div class="oneField field-container-D " id="tfa_114-D"> <label id="tfa_114-L" class="label preField " for="tfa_114">Parent/Guardian Name </label><br><div class="inputWrapper"><input type="text" id="tfa_114" name="tfa_114" value="" title="Parent/Guardian Name " class=""></div> </div> <div class="oneField field-container-D " id="tfa_109-D"> <label id="tfa_109-L" class="label preField " for="tfa_109">Date Signed </label><br><div class="inputWrapper"><input type="text" id="tfa_109" name="tfa_109" value="" title="Date Signed " class=""></div> </div> </div> </div></div> <div class="actions" id="4838790-A" data-contentid="submit_button"><input type="submit" data-label="Submit" class="primaryAction" id="submit_button" value="Submit"></div> <div style="clear:both"></div> <input type="hidden" value="334-f0d200ef137faa42a1685e79d90fc002" name="tfa_dbCounters" id="tfa_dbCounters" autocomplete="off"><input type="hidden" value="4838790" name="tfa_dbFormId" id="tfa_dbFormId"><input type="hidden" value="" name="tfa_dbResponseId" id="tfa_dbResponseId"><input type="hidden" value="93f6994eff989b2841634c69903ad630" name="tfa_dbControl" id="tfa_dbControl"><input type="hidden" value="" name="tfa_dbWorkflowSessionUuid" id="tfa_dbWorkflowSessionUuid"><input type="hidden" value="1732439452" name="tfa_dbTimeStarted" id="tfa_dbTimeStarted" autocomplete="off"><input type="hidden" value="3" name="tfa_dbVersionId" id="tfa_dbVersionId"><input type="hidden" value="" name="tfa_switchedoff" id="tfa_switchedoff"> </form> </div></div><div class="wFormFooter"><p class="supportInfo"><a target="new" class="contactInfoLink" href="https://www.tfaforms.com/forms/help/4725240" data-testid="contact-info-link">Contact Information</a><br></p></div> <p class="supportInfo" > </p> </div> </div> <script src='https://www.tfaforms.com/js/iframe_message_helper_internal.js?v=2'></script> </body> </html>