Register your Child in the SJIA Tiger Network

Parent/Guardian Information

Full Name *

Relationship to Child *

Phone (mobile) *

Email *

Home Address

Preferred Contact

Child Information

Child's Full Name *

Date of Birth *

Treating Physician(s)

Hospital/Clinic

Diagnosis * SJIA MAS Both

Media Consent & Preferences

Name Display Preference *

First name only Full name Anonymous (no name)

I understand I can withdraw consent in writing; previously published content may remain accessible.

Privacy, Use & Liability

By consenting, you allow GP Bosse 4 Foundation to use submitted content for awareness, education, and fundraising. We will not share personal details beyond what you provide. Materials published online can be viewed and shared by the public.

I am the parent/legal guardian and consent to the above use. * I exempt GP Bosse 4 Foundation, its directors, volunteers, and partners from liability related to media use. *

E-Signature

Type Your Full Name *

Must match the parent/guardian name above.

Date *

Draw Signature (mouse or finger)

Your drawn signature will be securely submitted with the form.

Questions? Contact gpbosse4foundation@gmail.com

Register your Child in the SJIA Tiger Network

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