Photo Session Intake
Email address *
Child's Full Name *
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Child's Birthdate *
Your answer
Person Filling Out This Form *
Your answer
Relationship to Patient *
Your answer
Phone Number *
Your answer
Alternative Contact *
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Relationship to Patient *
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Alternative Contact's Phone Number *
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Family preferred language *
Your answer
Child's Diagnosis *
Your answer
Case Details: Please check all that apply. *
Required
Availability: Please check all that apply. *
Required
If your child is currently hospitalized, what is hospital name and your child's room number?
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Photo session location preference (specify address in space below) *
Required
Location Name and Address, if applicable
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Child's mobility
Any additional healthcare related concerns that may affect the photo shoot (i.e. patient is on a vent, sensory and/or behavioral considerations, etc.)
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How many family members, in addition to the child, in the photo shoot?
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Would you be willing to sign a release for Little Light of Mine to share the photographs from your shoot on the organization’s website, Facebook page and/or marketing materials for purposes of bringing our services to other children and families? *
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