heide@wallofcourage.com | admin@wallofcourage.com

Please use the form below to add your child to The Wall of Courage.
FIELDS MARKED WITH A * ARE REQUIRED.

* Parent/Guardian name:	* Parent/Guardian e-mail:
* Child's name:	* Type of Brain Tumor:
* Age at diagnosis:	Current age (or "Forever Age"):
Comments:	* Birthday: Please enter a valid date.
	* Diagnosis Date: Please enter a valid date.
	Angel date: None
	Child's website:
Photo:	If we already have a photo on file and you are just updating info & permissions, you do not need to upload a photo. If you upload a new photo, we will replace the existing one.
PERMISSION TO CREATE GEAR I hereby give permission for my child's photo, name, and diagnosis information to be used to create "gear" (t-shirts, etc.). 100% of the proceeds from the sale of each child's individual gear will be donated to the Childhood Brain Tumor Foundation, in that child's honor/memory. Leave this box UN-checked if you would rather not have gear created for your child.	PERMISSION TO INCLUDE CHILD ON WEBSITE AND ON WALL I hereby give permission for my child's photo, name, and diagnosis information to be displayed on wallofcourage.com, and on our "real" wall.