Share Your Story – Children's Miracle Network Hospitals

Share Your Story

Children’s Miracle Network Hospitals understands that we are all interconnected through stories which can inspire, educate and even help raise the critical funds needed for our member hospitals. We are asking you to share your children’s hospital story with us so we can see the ripple effects that Children’s Miracle Network Hospitals have made to change kids’ health to change the future.

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Submit the form below to share your story.

Children’s Miracle Network Hospitals cannot guarantee that your story will be used. If additional information is needed, someone will reach out to you directly regarding the use of your story.

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Story Details*

Member Hospital*

Other Hospital*

Partner

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Location/Office Number

Program

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Authorization/Consent Statement*

I agree to the following terms regarding the use of my name, my child’s name, if applicable and the story submitted:*

By checking the box above and submitting your story and contact information, you agree to the following terms regarding the use of your name, your child’s name and the details of the story submitted.

You consent to, authorize, and grant Children’s Miracle Network Hospitals (“CMN Hospitals”) the absolute and irrevocable right and unrestricted permission to use your name, your child’s name, if applicable, and the story you have submitted, including information concerning your child’s medical condition (your “Names and Story”). You acknowledge and agree that your Names and Story may be used by CMN Hospitals for marketing, publicity, fundraising, awareness, promotions, campaigns and/or events throughout the world, in perpetuity, and may be edited or modified and used in any form of media by any manner (now and hereafter known). You, acting on your own behalf and on behalf of your child, if applicable, waive the right to inspect or approve any such uses of your Names and Story. CMN Hospitals may authorize hospitals, foundations, healthcare institutions, sponsors and/or others affiliated with CMN Hospitals to use your Names and Story.

All grants of permission and consent, and all covenants, agreements and understandings contained herein are irrevocable. You, acting in your own capacity and on behalf of your child, if applicable, waive any right to receive any additional payment or other consideration in exchange for the promises herein. You and your child, if applicable, hereby fully and forever release, discharge and hold harmless CMN Hospitals and its authorized hospitals, foundations, healthcare institutions, sponsors and other affiliates from and against any and all claims arising out of or related to the use of your Names and Story, and any claims for damages of any kind (including, but not limited to, invasion of privacy, defamation, false light, or misappropriation of name, likeness or image) arising out of the use or publication of your Names and Story. This release is intended to apply to all claims not known or suspected to exist with the intent of waiving the effect of laws requiring the intent to release future unknown claims. You certify and warrant that you have the legal authority to agree to these terms on your own behalf and on behalf of your child, if applicable, and that these terms shall apply to and bind all parents or guardians of your child, if applicable. This release shall be binding upon CMN Hospitals, you, your child, if applicable, and any other parent(s) or guardian(s) of your child, if applicable, and shall inure to the benefit of your and their successors, heirs, legal representatives, licensees, and assigns.

Your Name*

Please fill in your name to consent to the terms.*

First Last

Email*

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Phone*

Please fill in your phone number if you consent to the terms.*

Patient(s) Name(s)*

Full Name

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Chloe

OHSU Doernbecher Children's Hospital

Children’s Miracle Network Hospitals® raises funds for 170 children’s hospitals that support the health of 10 million kids each year across the U.S. and Canada. Donations go to local hospitals to fund critical life-saving treatments and healthcare services, along with innovative research, vital pediatric medical equipment, child life services that put kids’ and families’ minds at ease during difficult hospital stays and financial assistance for families who could not otherwise afford these health services. When we improve the health of all children and allow them the opportunity to reach their full potential, we also improve our communities for years to come. Together, we can change kids’ health. Together, we can change the future. To learn about Children’s Miracle Network Hospitals and your local children’s hospital, visit cmnhospitals.org.