Has your child reversed a chronic diagnosis, symptom or condition such as autism, ADHD, allergies, asthma, autoimmune disorder or mood/behavioral disorder? If you’d like to have your child’s story featured on our website, tell us about it here!

By Typing Your name below, your certify that you have read the consent information below the form and are the parent or guardian of the child and that you have read the terms of this agreement.

* *Must be signed by a parent or legal guardian in the case of a child under age 18 or legal guardian in the case of an adult (if applicable).

PLEASE READ THE FOLLOWING STATEMENT BEFORE SIGNING THIS CONSENT FORM. The undersigned subject of story, hereby grants Epidemic Answers, Inc. a nonprofit children’s health organization, the unrestricted permission, right and license to use the story and to reproduce, exhibit, broadcast, and advertise all or any part of the story in any media chosen by the organization. Epidemic Answers commits to concealing the name of the child or family, if this choice is indicated above. The undersigned is aware that the story maybe published by the organization in print or in electronic publications such as on the website(s) and may be released to other media and others in connection with the promotion or publicizing of the activities of the organization. Epidemic Answers shall own any copyright and all other intellectual property rights in the story. The undersigned waives any demand for compensation and waives any claim to any moral rights or any violation of rights to privacy, publicity or confidentiality under any statute or common law in connection with any use of the story. The organization proposes to act in reliance on this Consent, therefore the undersigned declares it to be irrevocable, and releases the organization from any and all claims, liability, actions or demands whatsoever in connection with the use of the story as provided in this Consent.