SIOD Superhero

Please complete the form below to be featured on our website & social media platforms. When the form is complete please send 3 or more images to

Parent Name *
Parent Name
SIOD Patient Name *
SIOD Patient Name
SIOD Patient Birthday *
SIOD Patient Birthday
Address (only state & country will be publicized) *
Address (only state & country will be publicized)
Release of information *
I grant permission to Kruzn for a Kure Foundation hereinafter known as the “Media” to use my image (photographs and/or video) and survey responses in Media publications. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.