#AllergyAlly Submissions

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.By completing this form you opting in to receive email communications from FARE.
example@example.com
3
State* This field is required.
4
Zip Code* This field is required.
5
Are you submitting a champion (someone with food allergies) or an ally (someone without food allergies)?
Champion
Ally
6
Who is a food allergy ally or champion in your life?* This field is required.(State "self" if you are nominating yourself)
7
What category do they fall into?
Please Select
Please Select
Caregiver
Friend
Family Member
Medical Professional
School Staff
Food Service/Hospitality
Political Representative
8
What are some of the things they do that make them an ally or champion?* This field is required.(Or that you do if you are nominating yourself)
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9
Share a photo of you as a food allergy champion, or you with your food allergy ally?* This field is required.The higher the quality image, the better.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
If you would like to be tagged, please include your social handles
11
Signature* This field is required.I hereby grant Food Allergy Research & Education (FARE) and its authorized representatives permission to use photographs/video footage of me and/or included minor children. I further agree that any or all of the material photographed/filmed may be used, in any form, as part of any future publications, brochure, or other printed or electronic materials used to promote FARE, and further that such use shall be without payment of fees, royalties, special credit or other compensation. 1. I give Food Allergy Research & Education (FARE) the right to use, reproduce, prepare derivative works, distribute copies of, and display my name, portrait, picture, likeness, biographical information and any other information supplied by me, in any manner or medium, except that this right does not include the right to use the aforementioned for a direct endorsement of any commercial product or service unrelated to the materials and services provided by FARE. 2. I agree that FARE will have ownership of all advertising, publicity, and other materials created or developed using my name, portrait, picture, likeness, biographical information and any other information supplied by me. I further agree that FARE will have all rights in such materials, including but not limited to, the right to use, reproduce, prepare derivative works, distribute copies of, and display the materials, and the right to license these rights to others. 3. I agree that FARE’s use of my name, portrait, picture, likeness, biographical information and any other information and material supplied by me will not violate the rights of any person or organization and will not impose any liability on FARE for payment to any person or organization. I also acknowledge that completing this form does not guarantee that I will be featured. By completing this form you opting in to receive email communications from FARE. I have read and understand the above:
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