{"id":128,"date":"2024-10-16T20:24:26","date_gmt":"2024-10-16T20:24:26","guid":{"rendered":"https:\/\/prrf.org\/prrf-minor-child-publicity-release\/"},"modified":"2024-10-18T00:30:01","modified_gmt":"2024-10-18T00:30:01","slug":"prrf-minor-child-publicity-release","status":"publish","type":"page","link":"https:\/\/prrf.org\/de\/prrf-minor-child-publicity-release\/","title":{"rendered":"PRRF Minor Child Publicity Release"},"content":{"rendered":"\n\t\t<div id=\"fws_6a156547afdb1\"  data-column-margin=\"default\" data-midnight=\"dark\"  class=\"wpb_row vc_row-fluid vc_row\"  style=\"padding-top: 0px; padding-bottom: 0px; \"><div class=\"row-bg-wrap\" data-bg-animation=\"none\" data-bg-animation-delay=\"\" data-bg-overlay=\"false\"><div class=\"inner-wrap row-bg-layer\" ><div class=\"row-bg viewport-desktop\"  style=\"\"><\/div><\/div><\/div><div class=\"row_col_wrap_12 col span_12 dark left\">\n\t<div  class=\"vc_col-sm-12 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone \"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t\n<div class=\"wpb_text_column wpb_content_element \" >\n\t<div class=\"wpb_wrapper\">\n\t\t<div class=\"sqs-html-content\">\n<h2 style=\"text-align: center; white-space: pre-wrap;\">PRRF Minor Child Publicity Release<\/h2>\n<\/div>\n<div id=\"form-submission-html-641a684726d7a82ce97c4d6c\" class=\"sqs-form-block-submission-html\" data-submission-html=\"\"><\/div>\n<div class=\"form-wrapper\">\n<div class=\"form-inner-wrapper\" hidden=\"\">\n<form action=\"https:\/\/website-admin-sja3.squarespace.com\" autocomplete=\"on\" method=\"POST\" novalidate=\"\" data-form-id=\"641a684726d7a82ce97c4d6c\" data-success-redirect=\"\" data-dynamic-strings=\"\">\n<div class=\"field-list clear\">\n<fieldset id=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073\" class=\"form-item field checkbox required\" aria-required=\"true\">\n<legend class=\"title\"> I give permission for my child&#8217;s image or interview to be used in the following manner:<\/legend>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"Media interviews (television, print, radio)\" \/> Media interviews (television, print, radio)<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"Podcast interviews\" \/> Podcast interviews<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"PRRF program brochures describing programs\" \/> PRRF program brochures describing programs<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"E-newsletters to the general public\" \/> E-newsletters to the general public<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"Virtual interviews and events (Zoom, Facebook, etc.)\" \/> Virtual interviews and events (Zoom, Facebook, etc.)<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"Online promotions (website, social media, etc.)\" \/> Online promotions (website, social media, etc.)<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"This release is unrestricted\" \/> This release is unrestricted<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-df149a25-7769-4070-b6f0-7a8471ca7073-field\" type=\"checkbox\" value=\"This release is only to be used in conjunction with (specify in the box below)\" \/> This release is only to be used in conjunction with (specify in the box below)<\/label><\/div>\n<\/fieldset>\n<div id=\"text-8bb04e3d-3314-4402-b5be-f92a0569cdf9\" class=\"form-item field text\">\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><input id=\"text-8bb04e3d-3314-4402-b5be-f92a0569cdf9-field\" class=\"field-element text\" type=\"text\" placeholder=\"Name specific event or manner that your image or interview can be used \" \/><\/div>\n<fieldset id=\"checkbox-7121423c-8402-490a-a851-28c70ec65b9a\" class=\"form-item field checkbox required\" aria-required=\"true\">\n<legend class=\"title\"> I give my permission for the use of my child&#8217;s:<\/legend>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"option\"><label><input name=\"checkbox-7121423c-8402-490a-a851-28c70ec65b9a-field\" type=\"checkbox\" value=\"First name only\" \/> First name only<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-7121423c-8402-490a-a851-28c70ec65b9a-field\" type=\"checkbox\" value=\"First and last name\" \/> First and last name<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-7121423c-8402-490a-a851-28c70ec65b9a-field\" type=\"checkbox\" value=\"Do not use their real name\" \/> Do not use their real name<\/label><\/div>\n<div class=\"option\"><label><input name=\"checkbox-7121423c-8402-490a-a851-28c70ec65b9a-field\" type=\"checkbox\" value=\"Medical diagnosis (as related to retinal diseases only)\" \/> Medical diagnosis (as related to retinal diseases only)<\/label><\/div>\n<\/fieldset>\n<fieldset id=\"name-ec75f62a-2b69-4b5c-944a-61a7d0c80895\" class=\"form-item fields name required\">\n<legend class=\"title\"> Minor Child&#8217;s Name<\/legend>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"field first-name\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" maxlength=\"30\" name=\"fname\" type=\"text\" data-title=\"First\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">First Name<\/span><br \/>\n<\/label><\/div>\n<div class=\"field last-name\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" maxlength=\"30\" name=\"lname\" type=\"text\" data-title=\"Last\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">Last Name<\/span><br \/>\n<\/label><\/div>\n<\/fieldset>\n<fieldset id=\"date-7816f12f-0834-45cb-8333-b4b1daaf891b\" class=\"form-item fields date required\">\n<legend class=\"title\"> Minor Child&#8217;s Date of Birth<\/legend>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"field month two-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"2\" type=\"text\" data-title=\"Month\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">MM<\/span><br \/>\n<\/label><\/div>\n<div class=\"field day two-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"2\" type=\"text\" data-title=\"Day\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">DD<\/span><br \/>\n<\/label><\/div>\n<div class=\"field year four-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"4\" type=\"text\" data-title=\"Year\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">YYYY<\/span><br \/>\n<\/label><\/div>\n<\/fieldset>\n<fieldset id=\"name-yui_3_17_2_1_1676767035262_2424\" class=\"form-item fields name required\">\n<legend class=\"title\"> My Information<\/legend>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"field first-name\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" maxlength=\"30\" name=\"fname\" type=\"text\" data-title=\"First\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">First Name<\/span><br \/>\n<\/label><\/div>\n<div class=\"field last-name\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" maxlength=\"30\" name=\"lname\" type=\"text\" data-title=\"Last\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">Last Name<\/span><br \/>\n<\/label><\/div>\n<\/fieldset>\n<fieldset id=\"address-6724bcf5-473c-4d2a-92bd-226cd98d678a\" class=\"form-item fields address required\">\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"field address1\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" name=\"address\" type=\"text\" data-title=\"Line1\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">Address 1<\/span><br \/>\n<\/label><\/div>\n<div class=\"field address2\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" name=\"address2\" type=\"text\" data-title=\"Line2\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">Address 2<\/span><br \/>\n<\/label><\/div>\n<div class=\"field city\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" name=\"city\" type=\"text\" data-title=\"City\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">City<\/span><br \/>\n<\/label><\/div>\n<div class=\"field state-province\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" name=\"state\" type=\"text\" data-title=\"State\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">State\/Province<\/span><br \/>\n<\/label><\/div>\n<div class=\"field zip\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" name=\"zipcode\" type=\"text\" data-title=\"Zip\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">Zip\/Postal Code<\/span><br \/>\n<\/label><\/div>\n<div class=\"field country\"><label class=\"caption\"><br \/>\n<input class=\"field-element field-control\" spellcheck=\"false\" name=\"country\" type=\"text\" data-title=\"Country\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">Country<\/span><br \/>\n<\/label><\/div>\n<\/fieldset>\n<div id=\"email-yui_3_17_2_1_1676767035262_2425\" class=\"form-item field email required\">\n<p><label class=\"title\" for=\"email-yui_3_17_2_1_1676767035262_2425-field\"><br \/>\nEmail Address<\/label><\/p>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><input id=\"email-yui_3_17_2_1_1676767035262_2425-field\" class=\"field-element\" spellcheck=\"false\" autocomplete=\"email\" name=\"email\" type=\"email\" aria-required=\"true\" \/><\/div>\n<fieldset id=\"phone-0a439942-6433-4594-80c2-8fd6687cd905\" class=\"form-item fields phone\">\n<legend class=\"title\"> Phone <\/legend>\n<div class=\"field text three-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"3\" type=\"text\" data-title=\"Areacode\" \/><br \/>\n<span class=\"caption-text\">(###)<\/span><br \/>\n<\/label><\/div>\n<div class=\"field text three-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"3\" type=\"text\" data-title=\"Prefix\" \/><br \/>\n<span class=\"caption-text\">###<\/span><br \/>\n<\/label><\/div>\n<div class=\"field text four-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"4\" type=\"text\" data-title=\"Line\" \/><br \/>\n<span class=\"caption-text\">####<\/span><br \/>\n<\/label><\/div>\n<\/fieldset>\n<div id=\"select-533d7185-86b0-4344-9084-32af34363f80\" class=\"form-item field select required\">\n<p><label class=\"title\" for=\"select-533d7185-86b0-4344-9084-32af34363f80-field\"><br \/>\nI understand and agree that any narratives, depictions, pictures, film, photographs, audio-visual or sound recordings or testimonials of me made by the Pediatric Retinal Research Foundation (PRRF) or its respective employees and agents may be used by PRRF, and those acting with permission, for illustration, broadcast, or testimonial shared with the general public in connection with the work of PRRF. I assign to PRRF all of my rights to these materials. I understand that these materials made by PRRF, its employees and agents are owned by PRRF and that they may copyright them. I further consent to allow PRRF, their respective employees and agents, and those acting with PRRF\u2019s permission, to use my protected health information, as defined under 45 C.F.R. 164.501, for the purpose of illustration, broadcast, or testimonial in connection with any work of PRRF, and to release this information to the general public. I understand that these materials may be published on PRRF\u2019s website, and this may disclose my personal and protected health information online. However, PRRF\u2019s online disclosure of my name and residence will be limited to my child\u2019s first name and the geographical location where he or she receives services. PRRF does not need to submit these materials to me for approval. I understand that these materials may be modified and that PRRF may decide not to use them. I acknowledge that the rights described above are granted to PRRF on an unlimited basis without any compensation or payment being made for any current or future use. I understand that my consent is voluntary, and that I may revoke my consent to allow PRRF to release my protected health information if that information has not already been disclosed. To revoke my consent, I must notify PRRF in writing. Such written notification must be sent to PRRF, Attn: Foundation Board President, PO Box 1926, Birmingham, MI 48012. I understand that a revocation is not effective to the extent that PRRF has relied on the use or disclosure of the protected health information. I understand and agree that once PRRF, its respective employees and agents, and those acting with permission, disclose my protected health information, this information may no longer be protected by the Health Insurance Portability and Accountability act of 1996. This release and authorization expire five (5) years from the date of my signature below. I have read this release and authorization before signing below, and I fully understand its contents.<\/label><\/p>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><select name=\"select-533d7185-86b0-4344-9084-32af34363f80-field\" aria-required=\"true\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><optgroup label=\"\"><\/optgroup><br \/>\n<\/select><\/div>\n<fieldset id=\"date-6d15ba04-de0a-47b7-97bf-f3141e11dde9\" class=\"form-item fields date required\">\n<legend class=\"title\"> Date<\/legend>\n<p><span class=\"required\" aria-hidden=\"true\">*<\/span><\/p>\n<div class=\"field month two-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"2\" type=\"text\" data-title=\"Month\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">MM<\/span><br \/>\n<\/label><\/div>\n<div class=\"field day two-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"2\" type=\"text\" data-title=\"Day\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">DD<\/span><br \/>\n<\/label><\/div>\n<div class=\"field year four-digits\"><label class=\"caption\"><br \/>\n<input class=\"field-element\" maxlength=\"4\" type=\"text\" data-title=\"Year\" aria-required=\"true\" \/><br \/>\n<span class=\"caption-text\">YYYY<\/span><br \/>\n<\/label><\/div>\n<\/fieldset>\n<\/div>\n<div class=\" form-button-wrapper form-button-wrapper--align-left \" data-animation-role=\"button\"><input class=\"button sqs-system-button sqs-editable-button sqs-button-element--primary\" type=\"submit\" value=\"Submit\" \/><\/div>\n<div class=\"hidden form-submission-text\">\n<p class=\"\" style=\"white-space: pre-wrap;\">Thank you for submitting your Adult Publicity Release to PRRF. If you have any questions please email info@pediatricrrf.org<\/p>\n<\/div>\n<div class=\"hidden form-submission-html\" data-submission-html=\"\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t<\/div>\n<\/div>\n\n\n\n\n\t\t\t<\/div> \n\t\t<\/div>\n\t<\/div> \n<\/div><\/div>\n\t\t<div id=\"fws_6a156547b03b2\"  data-column-margin=\"default\" data-midnight=\"dark\"  class=\"wpb_row vc_row-fluid vc_row\"  style=\"padding-top: 0px; padding-bottom: 0px; \"><div class=\"row-bg-wrap\" data-bg-animation=\"none\" data-bg-animation-delay=\"\" data-bg-overlay=\"false\"><div class=\"inner-wrap row-bg-layer\" ><div class=\"row-bg viewport-desktop\"  style=\"\"><\/div><\/div><\/div><div class=\"row_col_wrap_12 col span_12 dark left\">\n\t<div  class=\"vc_col-sm-2 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone \"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t\n\t\t\t<\/div> \n\t\t<\/div>\n\t<\/div> \n\n\t<div  class=\"vc_col-sm-8 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone \"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t<style id=\"wpforms-css-vars-6240\">\n\t\t\t\t#wpforms-6240 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-6240\"><form id=\"wpforms-form-6240\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"6240\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/de\/wp-json\/wp\/v2\/pages\/128\" data-token=\"7a4b97808611ec00bbae17b6fae96ef9\" data-token-time=\"1779787079\"><noscript class=\"wpforms-error-noscript\">Bitte aktiviere JavaScript in deinem Browser, um dieses Formular fertigzustellen.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Bitte aktiviere JavaScript in deinem Browser, um dieses Formular fertigzustellen.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-6240-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Minor&#039;s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6240-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-6240-field_0-error\" required><label for=\"wpforms-6240-field_0\" class=\"wpforms-field-sublabel after\">Vorname<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6240-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-6240-field_0-last-error\" required><label for=\"wpforms-6240-field_0-last\" class=\"wpforms-field-sublabel after\">Nachname<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-6240-field_13-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-6240-field_13\">Minor&#039;s Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6240-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" aria-errormessage=\"wpforms-6240-field_13-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-6240-field_14-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"14\"><fieldset><legend class=\"wpforms-field-label\">My Information <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6240-field_14\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][14][first]\" aria-errormessage=\"wpforms-6240-field_14-error\" required><label for=\"wpforms-6240-field_14\" class=\"wpforms-field-sublabel after\">Vorname<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6240-field_14-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][14][last]\" aria-errormessage=\"wpforms-6240-field_14-last-error\" required><label for=\"wpforms-6240-field_14-last\" class=\"wpforms-field-sublabel after\">Nachname<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-6240-field_11-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"11\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\">\t\t<div id=\"wpforms-6240-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-6240-field_2\" >My Information My<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-6240-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-6240-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-6240-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-6240-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-6240-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6240-field_9-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-6240-field_9\">Phone<\/label><input type=\"tel\" id=\"wpforms-6240-field_9\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][9]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-6240-field_9-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-6240-field_10-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"10\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-6240-field_10\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][10][address1]\" aria-errormessage=\"wpforms-6240-field_10-error\" required><label for=\"wpforms-6240-field_10\" class=\"wpforms-field-sublabel after\">Adresse Zeile 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-6240-field_10-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][10][address2]\" aria-errormessage=\"wpforms-6240-field_10-address2-error\" ><label for=\"wpforms-6240-field_10-address2\" class=\"wpforms-field-sublabel after\">Anschrift Zusatz<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-6240-field_10-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][10][city]\" aria-errormessage=\"wpforms-6240-field_10-city-error\" required><label for=\"wpforms-6240-field_10-city\" class=\"wpforms-field-sublabel after\">Ort<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6240-field_10-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][10][state]\" aria-errormessage=\"wpforms-6240-field_10-state-error\" required><label for=\"wpforms-6240-field_10-state\" class=\"wpforms-field-sublabel after\">Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-6240-field_10-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][10][postal]\" aria-errormessage=\"wpforms-6240-field_10-postal-error\" required><label for=\"wpforms-6240-field_10-postal\" class=\"wpforms-field-sublabel after\">Postleitzahl<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-6240-field_10-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][10][country]\" aria-errormessage=\"wpforms-6240-field_10-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>--- W\u00e4hle country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albanien<\/option><option value=\"DZ\" >Algerien<\/option><option value=\"AS\" >Amerikanisch-Samoa<\/option><option value=\"VI\" >Amerikanische Jungferninseln<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarktika<\/option><option value=\"AG\" >Antigua und Barbuda<\/option><option value=\"AR\" >Argentinien<\/option><option value=\"AM\" >Armenien<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AZ\" >Aserbaidschan<\/option><option value=\"AU\" >Australien<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BE\" >Belgien<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivien (Plurinationaler Staat)<\/option><option value=\"BQ\" >Bonaire, Sint Eustatius und Saba<\/option><option value=\"BA\" >Bosnien und Herzegowina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvetinsel<\/option><option value=\"BR\" >Brasilien<\/option><option value=\"VG\" >Britische Jungferninseln<\/option><option value=\"IO\" >Britisches Territorium im Indischen Ozean<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgarien<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CK\" >Cookinseln<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DE\" >Deutschland<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominikanische Republik<\/option><option value=\"DK\" >D\u00e4nemark<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estland<\/option><option value=\"SZ\" >Eswatini (K\u00f6nigreich)<\/option><option value=\"FK\" >Falklandinseln (Malwinen)<\/option><option value=\"FJ\" >Fidschi<\/option><option value=\"FI\" >Finnland<\/option><option value=\"FR\" >Frankreich<\/option><option value=\"GF\" >Franz\u00f6sisch-Guayana<\/option><option value=\"PF\" >Franz\u00f6sisch-Polynesien<\/option><option value=\"TF\" >Franz\u00f6sische S\u00fcd- und Antarktisgebiete<\/option><option value=\"FO\" >F\u00e4r\u00f6er-Inseln<\/option><option value=\"GA\" >Gabun<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GR\" >Griechenland<\/option><option value=\"GL\" >Gr\u00f6nland<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard- und McDonald-Inseln<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hongkong<\/option><option value=\"IN\" >Indien<\/option><option value=\"ID\" >Indonesien<\/option><option value=\"IQ\" >Irak<\/option><option value=\"IR\" >Iran (Islamische Republik)<\/option><option value=\"IE\" >Irland<\/option><option value=\"IS\" >Island<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italien<\/option><option value=\"JM\" >Jamaika<\/option><option value=\"JP\" >Japan<\/option><option value=\"YE\" >Jemen<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordanien<\/option><option value=\"KY\" >Kaimaninseln<\/option><option value=\"KH\" >Kambodscha<\/option><option value=\"CM\" >Kamerun<\/option><option value=\"CA\" >Kanada<\/option><option value=\"KZ\" >Kasachstan<\/option><option value=\"QA\" >Katar<\/option><option value=\"KE\" >Kenia<\/option><option value=\"KG\" >Kirgistan<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"CC\" >Kokosinseln (Keelinginseln)<\/option><option value=\"CO\" >Kolumbien<\/option><option value=\"KM\" >Komoren<\/option><option value=\"CD\" >Kongo (Demokratische Republik)<\/option><option value=\"CG\" >Kongo (Republik)<\/option><option value=\"KP\" >Korea (Demokratische Volksrepublik)<\/option><option value=\"KR\" >Korea (Republik)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"HR\" >Kroatien<\/option><option value=\"CU\" >Kuba<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"LA\" >Laos (Demokratische Volksrepublik)<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LV\" >Lettland<\/option><option value=\"LB\" >Libanon<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libyen<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Litauen<\/option><option value=\"LU\" >Luxemburg<\/option><option value=\"MO\" >Macau<\/option><option value=\"MG\" >Madagaskar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Malediven<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MA\" >Marokko<\/option><option value=\"MH\" >Marshall-Inseln<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauretanien<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexiko<\/option><option value=\"FM\" >Mikronesien<\/option><option value=\"MD\" >Moldau (Republik)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolei<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MZ\" >Mosambik<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NC\" >Neukaledonien<\/option><option value=\"NZ\" >Neuseeland<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NL\" >Niederlande<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"MK\" >Nordmazedonien (Republik)<\/option><option value=\"NF\" >Norfolkinsel<\/option><option value=\"NO\" >Norwegen<\/option><option value=\"MP\" >N\u00f6rdliche Marianen<\/option><option value=\"OM\" >Oman<\/option><option value=\"TL\" >Osttimor<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Pal\u00e4stina (Staat)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua-Neuguinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippinen<\/option><option value=\"PN\" >Pitcairninseln<\/option><option value=\"PL\" >Polen<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"RW\" >Ruanda<\/option><option value=\"RO\" >Rum\u00e4nien<\/option><option value=\"RU\" >Russland<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint-Barth\u00e9lemy<\/option><option value=\"PM\" >Saint-Pierre und Miquelon<\/option><option value=\"SB\" >Salomonen<\/option><option value=\"ZM\" >Sambia<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"SA\" >Saudi-Arabien<\/option><option value=\"SE\" >Schweden<\/option><option value=\"CH\" >Schweiz<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbien<\/option><option value=\"SC\" >Seychellen<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"ZW\" >Simbabwe<\/option><option value=\"SG\" >Singapur<\/option><option value=\"SX\" >Sint Maarten<\/option><option value=\"SK\" >Slowakei<\/option><option value=\"SI\" >Slowenien<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ES\" >Spanien<\/option><option value=\"SJ\" >Spitzbergen<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SH\" >St. Helena, Ascension und Tristan da Cunha<\/option><option value=\"KN\" >St. Kitts und Nevis<\/option><option value=\"LC\" >St. Lucia<\/option><option value=\"MF\" >St. Martin (franz\u00f6sisch)<\/option><option value=\"VC\" >St. Vincent und die Grenadinen<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Surinam<\/option><option value=\"SY\" >Syrien (Arabische Republik)<\/option><option value=\"ST\" >S\u00e3o Tom\u00e9 und Pr\u00edncipe<\/option><option value=\"ZA\" >S\u00fcdafrika<\/option><option value=\"GS\" >S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln<\/option><option value=\"SS\" >S\u00fcdsudan<\/option><option value=\"TJ\" >Tadschikistan<\/option><option value=\"TW\" >Taiwan, Republik China<\/option><option value=\"TZ\" >Tansania (Vereinigte Republik)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad und Tobago<\/option><option value=\"TD\" >Tschad<\/option><option value=\"CZ\" >Tschechische Republik<\/option><option value=\"TN\" >Tunesien<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks- und Caicosinseln<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkei<\/option><option value=\"US\" >USA<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"HU\" >Ungarn<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Usbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatikanstadt (Staat)<\/option><option value=\"VE\" >Venezuela (Bolivarische Republik)<\/option><option value=\"AE\" >Vereinigte Arabische Emirate<\/option><option value=\"GB\" >Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"WF\" >Wallis und Futuna<\/option><option value=\"CX\" >Weihnachtsinsel<\/option><option value=\"BY\" >Wei\u00dfrussland<\/option><option value=\"EH\" >Westsahara<\/option><option value=\"CF\" >Zentralafrikanische Republik<\/option><option value=\"CY\" >Zypern<\/option><option value=\"EG\" >\u00c4gypten<\/option><option value=\"GQ\" >\u00c4quatorialguinea<\/option><option value=\"ET\" >\u00c4thopien<\/option><option value=\"AX\" >\u00c5landinseln<\/option><option value=\"AT\" >\u00d6sterreich<\/option><\/select><label for=\"wpforms-6240-field_10-country\" class=\"wpforms-field-sublabel after\">Land<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-6240-field_7-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"7\"><fieldset><legend class=\"wpforms-field-label\">I give permission for my child\u2019s image or interview: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-6240-field_7\" class=\"wpforms-field-required\"><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_5\" name=\"wpforms[fields][7]\" value=\"Media interviews (television, print, radio)\" aria-errormessage=\"wpforms-6240-field_7_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_5\">Media interviews (television, print, radio)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_7\" name=\"wpforms[fields][7]\" value=\"Podcast interviews\" aria-errormessage=\"wpforms-6240-field_7_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_7\">Podcast interviews<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_9\" name=\"wpforms[fields][7]\" value=\"PRRF program brochures describing programs\" aria-errormessage=\"wpforms-6240-field_7_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_9\">PRRF program brochures describing programs<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_11\" name=\"wpforms[fields][7]\" value=\"E-newsletters to the general public\" aria-errormessage=\"wpforms-6240-field_7_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_11\">E-newsletters to the general public<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_13\" name=\"wpforms[fields][7]\" value=\"Virtual interviews and events (Zoom, Facebook, etc.)\" aria-errormessage=\"wpforms-6240-field_7_13-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_13\">Virtual interviews and events (Zoom, Facebook, etc.)<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_15\" name=\"wpforms[fields][7]\" value=\"Online promotions (website, social media, etc.)\" aria-errormessage=\"wpforms-6240-field_7_15-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_15\">Online promotions (website, social media, etc.)<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_17\" name=\"wpforms[fields][7]\" value=\"This release is unrestricted\" aria-errormessage=\"wpforms-6240-field_7_17-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_17\">This release is unrestricted<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_7_19\" name=\"wpforms[fields][7]\" value=\"This release is only to be used in conjunction with (specify in the box below)\" aria-errormessage=\"wpforms-6240-field_7_19-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_7_19\">This release is only to be used in conjunction with (specify in the box below)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6240-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-6240-field_12\">Name specific event or manner that the image or interview can be used<\/label><input type=\"text\" id=\"wpforms-6240-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-6240-field_12-error\" ><\/div><div id=\"wpforms-6240-field_8-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">I give permission for the use of my child\u2019s: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-6240-field_8\" class=\"wpforms-field-required\"><li class=\"choice-21 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_8_21\" name=\"wpforms[fields][8]\" value=\"First name only\" aria-errormessage=\"wpforms-6240-field_8_21-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_8_21\">First name only<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_8_23\" name=\"wpforms[fields][8]\" value=\"First and last name\" aria-errormessage=\"wpforms-6240-field_8_23-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_8_23\">First and last name<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_8_25\" name=\"wpforms[fields][8]\" value=\"Do not use their real name\" aria-errormessage=\"wpforms-6240-field_8_25-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_8_25\">Do not use their real name<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"radio\" id=\"wpforms-6240-field_8_27\" name=\"wpforms[fields][8]\" value=\"Medical diagnosis (as related to retinal diseases only)\" aria-errormessage=\"wpforms-6240-field_8_27-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_8_27\">Medical diagnosis (as related to retinal diseases only)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6240-field_6-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Conditions <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-6240-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6240-field_6_1\" name=\"wpforms[fields][6][]\" value=\"I agree to the following terms\" aria-errormessage=\"wpforms-6240-field_6_1-error\" aria-describedby=\"wpforms-6240-field_6-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6240-field_6_1\">I agree to the following terms<\/label><\/li><\/ul><div id=\"wpforms-6240-field_6-description\" class=\"wpforms-field-description wpforms-disclaimer-description\">I understand and agree that any narratives, depictions, pictures, film, photographs, audio-visual or sound recordings or testimonials of me made by the Pediatric Retinal Research Foundation (PRRF) or its respective employees and agents may be used by PRRF, and those acting with permission, for illustration, broadcast, or testimonial shared with the general public in connection with the work of PRRF. I assign to PRRF all of my rights to these materials. I understand that these materials made by PRRF, its employees and agents are owned by PRRF and that they may copyright them. I further consent to allow PRRF, their respective employees and agents, and those acting with PRRF\u2019s permission, to use my protected health information, as defined under 45 C.F.R. 164.501, for the purpose of illustration, broadcast, or testimonial in connection with any work of PRRF, and to release this information to the general public. I understand that these materials may be published on PRRF\u2019s website, and this may disclose my personal and protected health information online. However, PRRF\u2019s online disclosure of my name and residence will be limited to my child\u2019s first name and the geographical location where he or she receives services. PRRF does not need to submit these materials to me for approval. I understand that these materials may be modified and that PRRF may decide not to use them. I acknowledge that the rights described above are granted to PRRF on an unlimited basis without any compensation or payment being made for any current or future use. I understand that my consent is voluntary, and that I may revoke my consent to allow PRRF to release my protected health information if that information has not already been disclosed. To revoke my consent, I must notify PRRF in writing. Such written notification must be sent to PRRF, Attn: Foundation Board President, 8424 E 12 Mile Rd, Ste B2, Warren, MI 48093. I understand that a revocation is not effective to the extent that PRRF has relied on the use or disclosure of the protected health information. I understand and agree that once PRRF, its respective employees and agents, and those acting with permission, disclose my protected health information, this information may no longer be protected by the Health Insurance Portability and Accountability act of 1996. This release and authorization expire five (5) years from the date of my signature below. 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