Permission Request Form

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Hello and thank you for your interest in our materials!

In order to process your permission request, we need specific information about your organization and your intended use of our online health information.

Please review our Terms of Use, and Privacy Policy, then completely fill out and submit the permission request form below. Please allow 21 days for a response to your request.

Items marked with an asterisk * are required.

*I am a: Nonprofit Entity Corporate Profit Entity Individual

*Contact Name:

*Contact E-Mail Address:

Name of Nonprofit or Corporate Profit Entity:

Nonprofit or Corporate Profit Entity URL:

*Please describe your individual or your entity's mission/goals:

*Please list the name(s) and URL(s) of the materials for which you are requesting permission:

Please answer the following questions regarding how you plan to use these materials.

*Target Audience:

Educational Setting/Health Fair Name:

Print Publication Name:

*Will the material be distributed for free? Yes No

Additional Details:

*I have read and agree to the Legal Terms of Use Yes No

When you click "Submit" your request will be sent to our staff for consideration.

Please wait several seconds after clicking, for the form to be sent.

If you have any questions, comments, or difficulties with this form, please e-mail cywh@childrens.harvard.edu.

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