Share Your Walnut Warrior – Smashing Walnuts

Walnut Warrior Sign-Up Page

Parents, please fill out the below form and we will feature your Walnut Warrior on our website and/or social media.

Child's Name (required)

Are they currently battling cancer?

Child's Date of Birth (required)

Date of Diagnosis (required)

How is your child doing? (choose one)

Please share something about your child.
This text will appear on your child’s page. Please include information about your child’s diagnosis, prognosis, how they are doing, their favorite things (toys, books, sports, tv show etc.), accomplishments, any stories that would showcase their personality. You may also include a link to your website or Facebook page, Twitter, Instagram or other social media platforms. There is no text limit however Smashing Walnuts Foundation reserves the right to edit content for clarity and space limitations.

Pictures
Please upload up to 6 pictures of your child that we will include on his or her page.
Photos can be pictures of your child with their parents, siblings, extended family, friends, pets, before cancer, during treatment, your favorite picture of your child, a favorite family vacation photo.

[multifile warrior-photos limit:2mb filetypes:jpeg|jpg|png]
(Accepted file types: .jpg, .jpeg, .png and maximum accepted file size is 2mb)

Tribute Fund (optional)
Would you to include a link on your child’s page where people can contribute a tax-deductible donation to Smashing Walnut’s Foundation in honor of your child?
YesNo

Legal Waiver and Release

Does the Smashing Walnuts Foundation have permission to use your child's information (photos, name, age) in conjunction with Smashing Walnut’s programs including its website, social media accounts and promotional materials?
Please note: Your child’s information and photos will not be used for any purpose outside of the mission of the Smashing Walnut’s Foundation. We will not share any information or photos with other individuals or organizations (aside from their inclusion in public posts on our website and social media). You may revoke this permission at any time by contacting the Smashing Walnut’s Foundation in writing at Smashing Walnuts Foundation, PO Box 342, Leesburg, VA 20178 or via email at info@smashingwalnuts.org.

Yes, you may use my child's photos/name/age for Smashing Walnut’s Foundation projects.No, you may not use my child's photos/name/age for Smashing Walnut’s Foundation projects.You may only use my child's name/age.

By submitting your name and email, you are indicating you are the legal guardian of your child and that you have authority to provide permission to create Walnut Warrior page for your child and for any additional use of your child's name/photos as selected above in the legal waiver and release section.

Parent/Guardian Name (required)

Parent Email (required)

I want to be included on the Smashing Walnut’s Foundation email list.
I would be interested in contributing content (i.e. blog posts) for Smashing Walnut Foundation awareness building campaign efforts.

Address
We will not share your address with any third parties.
Street Address

Address Line 2

City

State

Zip

I understand that by submitting this form I am giving the Smashing Walnut’s Foundation permission to use the information and photo provided on their website, print, online, email and other awareness building campaign or other relevant channels as specified in this form. I may revoke my permission at any time by contacting the Smashing Walnut’s Foundation in writing at:
Smashing Walnuts Foundation
PO Box 342
Leesburg, VA 20178
Email: info@smashingwalnuts.org

Yes, I agree to these terms.