Page 7 - HERO Packet: Ginger Vitis
P. 7
Date: _____________________
I, ________________________________________, grant permission to America’s ToothFairy Name of parent/guardian
and/or DentaQuest to use my child/children’s image, voice, and/or words in informational materials such as reports, brochures, videos, and media. I waive all claims for compensation and release America’s ToothFairy and its sponsors from any liability related to such use.
Child/Children’s Name(s) Age(s) __________________________________________________ __________ __________________________________________________ __________ __________________________________________________ __________
I will ensure my child adheres to the Official Rules found at AmericasToothFairyKIDS.org.
Parent/Guardian Name (print): ________________________________________ Parent/Guardian Signature: ___________________________________________
Scan or take a photo of this form and include it when you submit your report online.
Submit your report at AmericasToothFairyKIDS.org.
America’s ToothFairy 4530 Park Road, Suite 320, Charlotte, NC 28209
