Help others navigate the pediatric epilepsy surgery journey

Stories are powerful ways to share our experiences, facts, and hard truths while also providing others with hope for the future. We seek diverse voices, experiences, and outcomes so that families anywhere on the pediatric epilepsy surgery journey can have a roadmap of what to expect.

With your permission, we'll use your child's story and photograph in various formats - and you'll always have the final say in what we publish. That's because we're committed to the highest standards of storytelling and have signed the Ethical Storytelling Pledge here.

Thank you for helping us get our message out!

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* 1. Your name

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* 2. Your email address

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* 3. Your child's first name

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* 4. Please describe your child's epilepsy surgery journey. We suggest no more than three paragraphs. We reserve the right to edit your comments for clarity and brevity; however,  we will provide you with the final language for your approval. 

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* 5. Has your or your child’s life been changed by a program, web content (including You Tube channel videos), surgical evaluation travel scholarship, family conference, or information you have accessed at The Brain Recovery Project? If so, please describe:

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* 6. Please upload a high quality photo of your child here. (Here are some tips for taking photos of your child if you need some inspiration.) 

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 7. May we contact you to be interviewed about an aspect of your child’s epilepsy surgery journey?

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* 8. Do you have a blog of your child's journey we can include on our website? If so, please share below.

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* 9. I hereby grant The Brain Recovery Project permission to use my minor child's likeness, without payment or consideration, in the following. I understand that I will be asked to give my final approval before publication:

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* 10. I understand and agree that all photos and videos will become the property of The Brain Recovery Project.

I hereby authorize The Brain Recovery Project to edit, alter, copy, exhibit, publish, or distribute these photos and videos for any lawful purpose with my prior approval.  Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I understand that there is no guarantee that my child's image and/or epilepsy story will be used for any reason by The Brain Recovery Project.

I hereby hold harmless, release, and forever discharge The Brain Recovery Project from all claims, demands, and causes of action which I, my child, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE AND ACCEPT:

TO ACCEPT, TYPE YOUR FULL NAME BELOW AND INCLUDE TODAY'S DATE

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