Meet The Kids Signup

Child's Name*

First Last

Is your child battling DIPG now?*

Yes
No

Child's Date of Birth

Child's Date of Passing

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

Max. file size: 63 MB, Max. files: 3.

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 Country

Meet the Kids Signup Page

Michael Mosier Defeat DIPG Foundation