To attend Celebration Day, please fill out and submit the form below.

Celebration Day RSVP

Patient Name (your name, not child's)(Required)

First Last

Patient DOB(Required)

Email(Required)

We will be attending Celebration Day in…(Required)

Lafayette with Dr. Storment – Children’s Museum of Acadiana, Sun Nov 1, 10am-12pm

Baton Rouge with Dr. Chappell and Dr. Malcom – Knock, Knock Children’s Museum, Sun Nov 1, 10am-12pm

Number attending (immediate family only please!)(Required)

Attendee #1 (First and last name)(Required)

Attendee #2 (First and last name)(Required)

Attendee #3 (First and last name)

Attendee #4 (First and last name)

Attendee #5 (First and last name)

Attendee #6 (First and last name)

Media Consent(Required)

I agree to the Media Consent

I, the undersigned, do hereby authorize and grant permission to Fertility Answers to use photographs, images, or video of me and/or my child(ren), family members, or guests taken at a Celebration Day event to use as the above mentioned deems necessary for the purpose of in-office display, publication in newspapers, magazines or other printed or digital media, for broadcast by means of radio and/or television transmission, or for display on Fertility Answers website(s) or online social media page(s), including, but not limited to, Facebook and Instagram. I understand that these photographs, images, or videos may be edited, modified, or retouched, at Fertility Answers’ discretion.

I understand this authorization will remain in effect until a written request for the removal of personal media is made. I understand that I have the right to revoke this authorization at any time through written notice. Upon receipt of written notice and within 30 days, Fertility Answers is obligated and required to remove my personal media from all electronic media, such as websites and social media platforms, owned and operated by Fertility Answers, and destroy any personal media, physical or electronic, in possession of Fertility Answers. I understand that, given the nature of media, my personal media may have been published, photocopied, shared, screenshot, or otherwise distributed beyond the control of Fertility Answers.

As such, I agree to forever hold Fertility Answers and its officers and employees free and harmless from any and all liability arising out of the use of my personal media and subsequent publication or broadcasting and release and forever discharge from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this release. I hereby release and forever discharge Fertility Answers from any and all claims and demands arising out of or in connection with the use of my personal media, including but not limited to any and all claims for libel. I understand that I have submitted these personal media under my own free will and so assume full responsibility.

Signature(Required)

Date Signed(Required)