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* required information
Tell Us About Yourself
First Name:
*
Last Name:
*
Email:
*
Contact Phone (optional):
I am a:
Please mark the appropriate checkboxes. You may select more than one category.
Hospital Employee
Nurse
Patient (Alumni)
Patient (Current)
Parent or Guardian of a Patient
Physician
Researcher
Supporter
Volunteer
In Memory Of
Tell Us Your Story
Your Story Text:
*
500 words or less
Title for the Story:
*
e.g. "Joey's Story"
Subtitle for the Story (optional):
e.g. "Overcoming Cancer one Day at a Time"
Byline:
e.g. "By his father, Joe"
Upload a Photo:
Your photo must be less than 4MB in size and be one of the following formats: .jpg, .bmp, or .gif.
Click here to attach file
Website Link:
Do you have a website or webpage that expands on the story you have shared? If so, please add the link here.
Videoshare Link
Do you have a video that expands on the story you have shared here? If so, please provide the link to the video sharing site (such as YouTube, VideoJug, etc.) where others may watch your video.
I have read and understand the reasons why my story may not be used on this website.
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I have read and understand the usages of my story and release Childrens Hospital Los Angeles to contact me should any revision need to be made.
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