Pediatric Spine Foundation

Please fill out the form below and upload any pictures and videos you would like to share. If you have any questions, please contact the Pediatric Spine Foundation at info@pediatricspine.org.

Other Facts About You

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By submitting my story or my child's story, I understand and agree to allow the Pediatric Spine Foundation to use the information, photo and/or video for marketing, publicizing, or otherwise promoting the Pediatric Spine Foundation's mission and that the information may be disseminated in any medium without geographic or time restriction. I authorize the release of any information including health information contained in this submission and authorize the staff of the Pediatric Spine Foundation to discuss this information with physicians and other staff, as necessary to verify the accuracy of the information. I waive and release Pediatric Spine Foundation from any and all claims that I may have against Pediatric Spine Foundation or its officers, directors, employees, agents, or affiliates arising out of its use or dissemination of this information. I also waive any right to royalties or other compensation for Pediatric Spine Foundation use and dissemination of this information. I assign all rights, including copyright, to the Pediatric Spine Foundation. I represent and warrant that I have the authority to provide the information to the Pediatric Spine Foundation and that no one else owns or has superior rights to this information. I have read, fully understand, and voluntarily agree to be legally bound by this waiver, release, and authorization form. I understand and agree that I may not use this site to conduct any activity that is illegal or that violates the rights or others. I represent and warrant that all information submitted is truthful and accurate.