A form to collect patient and family stories for Conquering CHD.
Basic personal and contact details.
Enter your first name.
Enter your last name.
Enter your city.
Enter your state.
Enter your age.
Enter the patient's diagnosis.
Enter your email address.
Select all that apply.
Share how you became connected with Conquering CHD.
Share your CHD story.
Share your patient or family member story in 600 words or less.
Upload at least 3 photos of good quality.
Legal consent and communication preferences.
I hereby grant Conquering CHD royalty-free, non-exclusive, perpetual (for the duration of the applicable copyright) license to reproduce the photograph(s), to incorporate the photograph(s) into one or more Collective Works (including but not limited to newsletters, websites, and any other media or publications as the above named organizations deem appropriate for promoting advocacy activities), and to reproduce the photograph(s) as incorporated in the Collective Works. The above rights may be exercised in all media and formats whether now known or hereafter devised. The above rights include the right to make such modifications (including but not limited to cropping or altering the photograph(s) as are technically necessary to exercise the rights in other media and formats.
Check if you do not wish to receive postal mail from Conquering CHD.