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BrightFocus Event Consent Form

I authorize BrightFocus Foundation to use the materials identified below for purposes of sharing information. Materials about my event can be used by BrightFocus in its publications, presentations website, Facebook and other social media vehicles. These materials will help increase awareness of Alzheimer's, macular degeneration and glaucoma. 

 

* Indicates a required field

I am submitting the following: *

If you chose "Other," please describe below:

 

Contact Information: *

First Name

Last Name

Phone

Email

 

Event Information: *

Name of Event

Location of the Event

 

Share your Story: *

 

Describe Your Photograph(s), Video(s), Audio Recording(s), or Written Material(s): *

 

Provide Notes/Limitations on use of the Photograph(s), Video(s), Audio Recording(s), or Written Material(s): *

 

List the Names of all Individuals in Photograph(s), Video(s), Audio Recording(s), or Written Material(s): *

 

Do the people in the photo have a connection to Alzheimer’s disease, macular degeneration, and/or glaucoma? If yes, please describe:

 

Upload Photo/Image 1
(must be < 4 MB)

  

Upload Photo/Image 2
(must be < 4 MB)

Video Uploads

Please provide your YouTube link:

 

 

Please enter the text from the image below. *


     

Last Review: 01/22/14


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