Full name
Email
Image
Description
I affirm that I am age 18 or older. I hereby consent to the use of my name and likeness for the purpose of promoting organ and tissue donation. This consent is given without obligation of any kind.I affirm that I am the legal next of kin for the person in this story submission. I hereby consent to the use of his or her name and likeness for the purpose of promoting organ and tissue donation. This consent is given without obligation of any kind.I am the parent/guardian of the child in this story submission. I hereby consent to the use of his or her name and likeness for the purpose of promoting organ and tissue donation. This consent is given without obligation of any kind.
Signature