Hearts of Hope Portal Registration Primary Contact Full Name*This will be the main contact for your family.Primary Contact Phone Number*Let us know the best phone number to reach you.Primary Email Address* Enter Email Confirm Email This will be the main email address used to contact your family and set up your Hearts of Hope Network portal account.Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Family StoryOne of the things we love to do is to write up a little bit of your story to share with others. In this story, we write a little about your family situation and if you have any personal fundraising links, we put them here as well so people can continue to support your family. Tell us your family story. We will use this material to write your story on our website. We may quote you directly or make small changes for grammar and clarity. You will also be able to add/ edit this in your portal.Photos Drop files here or Select filesMax. file size: 512 MB.Attach family or individual photos we can use to add your story to our website. This can also be done later in your portal.Social Media Photos Hearts of Hope Network is allowed to use photos gathered from our social media accountsMany times families have great pictures of their family or children in their social media accounts and don't even realize it. If you want to skip the uploading of files or want to give us the ability to pick out pictures from your social media accounts, please let us know by checking the consent box below. If not, please leave the box unchecked.Publicity OptionsParticipants understand and agree that the fulfillment of the aid or gifts made by Hearts of Hope Network may result in publicity, whether or not Hearts of Hope Network actively takes steps to publicize the aid or gifts. However, to the extent Hearts of Hope Network has control over the matter, Hearts of Hope Child’s parents or guardians are asked to choose between the following two alternatives. Note: By completing and submitting this Release and Authorization, all other participants (or their parents/guardians if under the age of 18) agree to be bound by the “publicity option” chosen by Hearts of Hope Child’s parents or legal guardians. Only photos and names provided by the Parent or Legal Guardian will be included in publications, it is the responsibility of these individuals to obtain any additional needed permissions for Hearts of Hope Network to use these materials prior to submitting them.Please Choose One* OPTION 1 [Publicity O.K.]: Participants authorize Hearts of Hope Network to publicize the support and/or gifts and to use Participants’ names, likenesses and other information about Participants and the gifts of aid (including Hearts of Hope Child’s medical condition), whether embodied in photographs, videos, recordings or any other format (collectively, “Information”), for purposes of promotion, publication, commercial advertising, or any other purpose whatsoever, now or at any time in the future without the payment of royalties or other compensation. OPTION 2 [Prefer no publicity]: Participants request that information about their involvement in Hearts of Hope Network not be actively publicized by Hearts of Hope Network to the electronic or print news media, posted on the Internet, or used in Hearts of Hope Network “collateral” such as newsletters, brochures, annual reports, etc. However, each Participant understands and agrees: (1) that information regarding the aid and gifts and Participants will necessarily be discussed with and disclosed to those involved in the wish process; (2) that Hearts of Hope Network may publicly describe and promote the support and/or gifts generally, without specifically identifying Participants; and (3) that even if Hearts of Hope Network does not actively publicize the support or gifts, the general public and media may obtain information concerning Participants’ involvement in Hearts of Hope Network from other sources.Publicity ConcernsIf you have any publicity concerns, please state them here.Liability ReleaseRelease* I agree to the liability releaseParticipants understand that involvement in the Hearts of Hope Network program may include financial and physical gifts (Tony’s Hugs packages) benefiting the family of the critically ill child. In consideration of Hearts of Hope Network considering the granting of aid or Tony’s Hugs packages and, if it so determines, granting the aid and gifts, the Participants hereby release and agree to hold Hearts of Hope Network harmless for, from and against any and all liability, damages and claims (“Claims”) of any kind, known and unknown, which may be connected with, result from, or arise out of the consideration, preparation, fulfillment or participation in Hearts of Hope Network. This includes, but is not limited to, Claims involving economic loss, illness or medical condition, accidental injury or death. The recipient and/or legal Parents/ Guardians hold full responsibility for the proper usage and safety of any and all gifts received.SubmissionBy submitting this completed form to Hearts of Hope Network; I hereby agree, represent and warrant that I/we have read the foregoing release and have executed it freely and voluntarily.