Believe Ball Participation | Emily Whitehead Foundation

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Please choose one... (required)(Required)

I am the parent / guardian of a child who received (or will receive) CAR-T
I am the parent / guardian of a child diagnosed with cancer (did not receive CAR-T)
I am an adult patient who received (or will receive) CAR-T

Are you... (required)(Required)

The parent/guardian of a child diagnosed with cancer
An adult diagnosed with cancer

Have you or will you receive CAR-T therapy? (required)(Required)

Yes - have received
Yes - will receive / trying to receive
No - do not need CAR-T

This includes any CAR-T in a clinical trial or any FDA approved CAR-T product.

Child's name (required)(Required)

Parent name (required)(Required)

Your name (required)(Required)

Email (required)(Required)

Address (required)(Required)

Phone (optional)

Child's current age (required)(Required)

Child's age when they received CAR-T cell therapy (required)

What is your age? (optional)

Year that you / your child were treated with CAR-T cell therapy (required)

Enter 4 digits, for example: 2019

Hospital where you / your child received CAR-T cell therapy (optional)

If you do not want to share this information, entering just the state where the hospital is located is helpful, or enter N/A.

Type of cancer (optional)

Participation Opportunities

Are you interested in contributing artwork for the silent auction? This can be any type of artwork; for pediatric patient families, siblings are also welcome to submit something! We will be in touch with more details.

Yes

Are you interested in submitting a short message for the event program (including photo)?

Yes

Are you interested in participating in submitting your photo for the event collage? Since we are unable to get together in person for a group photo, we are putting together a photo collage of CAR-T patients to show at the end of the event. ***The group photo we took in 2017 has been shared around the world!***

Yes

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Do you know what you plan to submit? If not, that’s okay! You can let us know later.

Painting (canvas)
Painting or drawing (paper)
Other

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If "Other", please describe here:

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How would you like your name to appear as the artist?

Add as much or as little info as you would like. Example: "Lucy Smith, age 6, received CAR-T in 2016" OR "Lucy, age 6, CAR-T recipient" etc.

Please describe your CAR-T story in a short paragraph, how you are doing, future plans/goals, and include any message you would like to say to doctors/researchers/hospital staff.

If you need some time to write this, just leave us a note that you will send it later (email it to believeball@emilywhiteheadfoundation.org)

Please upload your photo.

If you have difficulty uploading a photo, or would like to send one later, please email it to: believeball@emilywhiteheadfoundation.org

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

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Please upload a photo to use for the event mosaic.

If you have difficulty uploading a photo, or would like to send one later, please email it to: believeball@emilywhiteheadfoundation.org

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 10 MB.

If you would like to tell us more about your diagnosis, treatment, current status, etc. please let us know below. (optional)

Would you be interested in sharing your story in a longer format on our blog?

Yes
No

Comments and Suggestions for EWF or about the Believe Ball

Comments / suggestions / questions

Photo / Story Release*

Photo / Story Release: (required)(Required)

By checking this box, I confirm that I agree to and accept the below terms and conditions governing my or my child’s participation in the Foundation Mission.

I authorize the Emily Whitehead Foundation and its representatives to use my child’s name, diagnosis, photographs, video recordings, my name, and my child’s story to inform its supporters, the media and the general public about the Emily Whitehead Foundation and its programs, events, fundraising and services. These materials may be used in but not limited to promotional materials, social media posts, newsletters/emails and the organization’s web site. If authorized above, I, for my child and myself release all claims against the Emily Whitehead Foundation, its representatives, and volunteers, with respect to copyright ownership and publication, including any claim for compensation related to the use of these materials.

I grant the Foundation the right to use each of my, my spouse’s, partner’s, and/or the child/ren’s name as set forth below: (required)(Required)

use my/my child's first and last name
use my/my child's first name only

Comments

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