Patient Story Application We’re honored to consider your story. Please complete the below form to provide us with the details and we’ll be in touch! Are you or your child the Patient affected by CHD? * I was affected by CHD My child was affected by CHD Patient Information * First Name Last Name Email Consent for Use of Testimonial I, the undersigned, hereby grant permission to Heart Warrior Ministries and its affiliates, employees, agents, and representatives to use my testimonial, including any photographs, videos, or other media content related to my testimonial, for marketing, promotional, and educational purposes. This includes, but is not limited to, use on websites, social media, print materials, and other digital or print media. * Initial to accept these terms Patient Story Please write your/your child's story describing their journey with CHD (please keep to less than 350 characters, about three paragraphs long) Is there a nonprofit set up in honor of or because of your experience with CHD? Yes No If yes, please list the link you would like viewers to go to here: http:// 1. Usage: I understand that my testimonial may be used in various forms of media, including but not limited to brochures, newsletters, websites, social media platforms, and other promotional materials.2. No Compensation: I acknowledge that I will not receive any monetary compensation for the use of my testimonial or related media content.3. Right to Revoke: I understand that I have the right to revoke this consent at any time by providing written notice to Heart Warrior Ministries. However, revocation will not affect any materials that have already been produced or distributed prior to the receipt of my revocation.4. No Obligation to Use: I understand that Heart Warrior Ministries is under no obligation to use my testimonial and that the organization retains full discretion over the use and publication of my testimonial.5. Release of Liability: I hereby release and hold harmless Heart Warrior Ministries, its affiliates, employees, agents, and representatives from any claims, demands, or liabilities arising out of or in connection with the use of my testimonial, including any claims for defamation, invasion of privacy, or misappropriation.6.Duration: This consent is given in perpetuity and remains effective unless revoked as outlined above.By signing below, I acknowledge that I have read and understand the terms and conditions of this consent form and agree to the use of my testimonial as described. * Date:* MM DD YYYY It’s our privilege to help provide formula for you."Do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God."Philippians 4:6
