First Name
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Last Name
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Email
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Phone Number
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Artwork Title
Artwork Narrative
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Please use 1000 characters or less
1000
I am a
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Person diagnosed with cancer
Family member of a person diagnosed with cancer
Friend or loved one of a person diagnosed with cancer
Healthcare Professional
Other
Artwork Submission (10mb Max upload size)
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Accepted file types: .pdf, .jpg, .png
I am submitting on behalf of a minor
By checking this Consent and Release box, I consent to the following
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I consent to allow the above named minor to participate in the WellSpan Health Digital Art Gallery and for the personal information about the above named minor to be used and shared as described in the Digital Art Gallery Program Terms. I represent and warrant that (i) I am eighteen (18) years of age or older and I am legally competent to execute this Consent and Release Form under the laws of my country, (ii) I have the legal authority to represent the above named minor, and (iii) I have read and understand this Consent and Release Form and the Digital Art Gallery Program Terms and (iv) voluntarily sign this Consent and Release Form on behalf of the above named minor.
I have read and accept the
Virtual Art Gallery Program Terms
.
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