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Meet the Kids Signup Page
Include your child in this page of brave children who are battling or have battled DIPG.
Please complete the following information to create a page for your child on the Meet the Kids portion of our website. We will create the pages as soon as possible after submission and send an email to confirm when it is live.
Child's Name
*
First
Last
Is your child battling DIPG now?
*
Yes
No
Child's Date of Birth
MM
DD
YYYY
Child's Date of Passing
MM
DD
YYYY
Text for Meet the Kids Page
*
Please provide whatever text you would like to appear on your child's page. If you wish for a link to a Facebook or other page to be included, please put them in the text. We do not have a length limit, so you may include whatever you wish, but we recommend staying within 3-4 paragraphs. You may make the text much shorter if you wish as well.
Pictures
Please upload 3 pictures of your child/family that we will include on his or her page.
Drop files here or
Please indicate whether you provide permission to use your child's information (photos, name, and/or age) for DIPG awareness projects.
*
Checking "yes" on this item would allow Michael Mosier Defeat DIPG Foundation to include your child's pictures for purposes of future DIPG awareness projects. Obtaining permission in advance preserves resources by enabling us to include a range of children in projects without sending individual requests each time. As an example, we sometimes create graphics with photos of multiple children for social media, the website, or print materials for DIPG events. The photos would not be used for any purpose outside of the mission of Michael Mosier Defeat DIPG Foundation, and we always treat children with the utmost respect. We will not share any information or photos with other individuals or organizations (aside from their inclusion in public posts). You may revoke this permission at anytime by sending an email to info@defeatdipg.org.
Yes, you may use my child's photos and/or name/age for DIPG-focused projects.
No, you may not use my child's photos or name for DIPG-focused projects.
You may use my child's name/age but not the photos.
Please contact me by email for permission for each project.
Tribute Fund
*
Would you like us to include a custom link on your child's page where people can make tax-deductible donations to research in honor of your child? This is optional.
Yes
No
Notification of Tribute Fund Donations
*
Pleae indicate if you agree to receive notifications of tribute fund donations in honor/memory of your child via email. If "yes," we will send the notification to the email address provided in this form. If you want notification to go to a different or additional email address, please select "other" and include the information there. We will provide notifications on a monthly basis.
Yes
No
Parent Name
*
By submitting your name and email, you are indicating you have authority to provide permission to create the Meet the Kids page for the child and any additional use of the child's name/photos as described above.
First
Last
Parent Email
*
I want to be included on the Michael Mosier Defeat DIPG Foundation email list.
Address
Optional. We will not share your address with any third parties. It would only be used to assist us in identifying families in different geographic areas or for hard copy mailings from Michael Mosier Defeat DIPG Foundation. If you do not wish to provide a full address, please just include your state of residence.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
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Angola
Anguilla
Antarctica
Antigua and Barbuda
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Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
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Finland
France
French Guiana
French Polynesia
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Gambia
Georgia
Germany
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Greenland
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Guadeloupe
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Isle of Man
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Italy
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Jordan
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Lesotho
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Panama
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Paraguay
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Pitcairn
Poland
Portugal
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Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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Sweden
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Togo
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Tonga
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Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
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