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* 1. Parent's Name

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* 2. Child's Name (will not be used in flyer campaign)

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* 3. Child's Age at Onset 

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* 4. Address so we can look up your legislator and district.

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* 5. "PANDAS IS".... (2-3 sentences please, we may shorten if too long)

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* 6. PANDAS/PANS onset symptoms that your child had (OCD, rage, bedwetting, etc)

I hereby grant NWPPN permission to use my submitted photograph in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of the NWPPN and will not be returned.

I hereby irrevocably authorize NWPPN to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my child's likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge NWPPN from all claims, demands, and causes of action which I, 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 PHIOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:

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* 7. Signature in Agreement

PLEASE SEND 1-2 PHOTOS OF YOU OR YOU AND YOUR PARTNER TO nwestppn@gmail.com   
We THANK YOU for your participation in this campaign which will be used for the 2021 legislative session and potentially other NWPPN marketing efforts.  Together we can make a difference and raise awareness for PANDAS/PANS here in the Northwest.

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Faces of PANDAS/PANS Example

Faces of PANDAS/PANS Example
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 100% of survey complete.

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