Our Krabbe Heroes | KrabbeConnect

To submit a photo of your hero, please provide:

A high resolution image, if possible
The first name you’d like to display and initial of last name
The city and state of pictured individual
Complete Permission to Use Photograph form below

Permission to Use Photograph
Informed Consent

Photography, Video, Audio Recordings

I (the undersigned individual) hereby grant full permission to KrabbeConnect and its employees, legal representatives, agents, representatives, successors, assignees and assigns (collectively, the “Authorized Parties”) to take my or my minor child(ren)’s photograph, videoclip or sound recording and to use or reproduce such items, as well as my or my minor child’s name and any other information provided by me about me or my minor child(ren) (collectively referred to as the “Materials”) for any purpose in the Authorized Parties’ sole and exclusive discretion. I represent that I am 18 years of age or older. I understand that the Authorized Parties may adapt, modify, reproduce, distribute, publish, display and create derivative works of the Materials and that the Authorized Parties have no obligation to compensate me in any way for any use of the Materials. I understand and agree that the Authorized Parties are and will be the exclusive owner of all right, title and interest, including copyright, in works of authorship which they create and which incorporate the Materials. I expressly release the Authorized Parties from any and all claims which I have or may have in the future for invasion of privacy or any other cause of action arising out of the uses of the Materials herein granted, even if the usage of the Materials is objectionable to me.

I represent that if this Informed Consent relates to my minor child(ren), I am the parent or legal guardian of the below-named minor child(ren).
Name of Minor Child(ren) (if applicable)
Your Name (Parent/Caregiver of minor patient)*
For Our Records Only, will not be displayed publicly.
First Last
Caregiver relationship*
- Parent
- Grandparent
- Other
Name of Adult affected by Krabbe disease (if applicable)
Your Mailing Address*
For Our Records Only, will not be displayed publicly.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Street Address
If different from above. For Our Records Only, will not be displayed publicly.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Email*
For Our Records Only, will not be displayed publicly.
Your Phone*
For Our Records Only, will not be displayed publicly.
Heroes Name and Information
Name to Display: First Name and Initial of Last Name*
(Ex. Jane D.)
City and State to Display:*
Country Hero was born in
State/Providence Hero was born in
Hero’s Birthdate
MM slash DD slash YYYY
Hero’s Death Date (if applicable)
MM slash DD slash YYYY
Diagnosis and Treatment Information
Links to Your Hero's Story (News/Blog Articles, Videos, etc.)
Upload Photo*
Please upload a photo in as high of resolution as possible. Files must be JPG or PNG format. Max file size is 5MB.
Accepted file types: jpg, png, jpeg, jpeg, Max. file size: 5 MB.
Join Our Mailing List
- Yes! Please add me to your emailing list to receive occasional updates about new Krabbe research and new website content.
Your Signature*
Please Verify You Are a Real Person
Name
This field is for validation purposes and should be left unchanged.

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Permission to Use Photograph

Informed Consent

Heroes Name and Information

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Newly Diagnosed

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Permission to Use Photograph

Informed Consent

Heroes Name and Information

Join Our Mailing List

Search

Contact Us

OUR VISION

Newly Diagnosed

Patients & Caregivers

Research & Education