Rules and Consent for Participation in“My Story,” E-newsletter stories,
Publicity, Promotion, Marketing and Advertising

To participate in CCFA’s “My Story” feature, please do the following:

  1. Fill out the consent form below and e-mail it to
  2. Send us your story of no more than 750 words in electronic format (e-mail or Word document). Please do not refer to specific doctors, nurses, or other healthcare professionals.
  3. Send us two to three digital photographs of yourself or the story subject. File size should be at least 1MB.

Name: ______Telephone ______

Address:______

Age: ______

(If participant is under 18 years of age)

  1. By submitting my story and photograph(s) to CCFA, I grant, in perpetuity, the Crohn's & Colitis Foundation of America (CCFA) or its authorized agent permission to publish, reproduce, record and use my story as CCFA or the authorized agent sees fit in any medium or forum in a manner which helps to further the CCFA mission without further notice or compensation. I agree to release and hold harmless CCFA from any and all liability by any third party that may arise from the release of information to any third party or by any third party and agree that all text and other content made by me, for me or the person for whom I am the parent/guardian, shall be the exclusive property of CCFA. CCFA cannot verify every claim made by a third party contributor and is not responsible for the authenticity of information posted.In compliance with the Children's Online Privacy Protection Act of 1998, if Entrant is under the age of 13, Sponsor must obtain verifiable parental notice and consent prior to the collection, use, or disclosure of personal information.
  2. Irecognize that third party media organizations have exclusive control over the information and material they gather and I acknowledge that the Crohn’s & Colitis Foundation of America has no control over or responsibility for the manner in which the information and material cited above will be used, including its re-distribution to other third party media not listed above.
  1. I hereby release and agree to indemnify the Crohn’s & Colitis Foundation of America and its affiliates, successors and assigns and their respective employees, trustees and agents from and against any and all liability, including reasonable attorneys fees, arising out of the exercise of the rights granted by this consent.

Signature:______Date: ______

(Participant, Personal Representative or Legal Guardian)

Witness:______Print Name______

Personal Representative or Legal Guardian: [Print Name]______

Authority______Telephone: ______

Address: ______