MCH Share Your Story

MCH SHARE YOUR STORY

Name *

First

Last

Child's Name *

First

Last

Phone *

Email *

Dates of Stay at RMHC of the Southwest - PB *

What is your child's diagnosis/story? *

Please be as descriptive as possible.

How is your child doing now? *

What would you say about the experience you had while at RMHC to our supporters (donors, volunteers, others)? *

What did you enjoy most about your stay at RMHC of the Southwest - PB, or what was your favorite memory? *

Is there anything else you'd like to add about your stay?

Do you have a photo of your child/family we can use to tell your story? If so, upload below.

Click or drag a file to this area to upload.

I hereby grant to RMHC of the Southwest, or anyone authorized by them, my full permission, irrevocably and in perpetuity, the right, license, and privilege to use, reproduce, represent, exhibit, transmit, and simulate the undersigned's, and/or my child's name, likeness, photograph, and statements worldwide, in any manner and form and by any method and process and through any media now or hereafter known or devised. I guarantee that the statements given by me reflect my true experience with RMHC of the Southwest. And, I agree that my statements may be reasonably edited.

Signature

Please confirm by checking below: *

I certify that I am at least 18 years of age.
I am the parent/legal guardian of any child featured in submitted photo.

Phone