Prevent Blindness Story and Advocacy Submission Form

Upload a Profile Picture (optional)

First Name *

Enter your first name.

Last Name *

Enter your last name.

Address *

Enter your address.

City *

Enter your city.

State *

Enter your state.

Select a state…AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoU.S. Virgin Islands

Zip Code *

Enter your zip code.

Email *

Enter your email address.

Social Media Accounts

Provide links to your social media accounts (optional).

What is your connection to Prevent Blindness? *

Select all that apply.

Do you have a vision condition/disease? *

What is your vision condition/disease?

Select your vision condition/disease.

Select…Age related macular degenerationGeographic Atrophy (GA)Diabetic RetinopathyDiabetic Macular EdemaStargardtRetinitis PigmentosaGlaucomaCataractsDry eyeUveitisOther autoimmune condition (e.g., Sjogren’s or Multiple Sclerosis)Thyroid Eye Disease

Are you a parent or caregiver of someone with a vision impairment? *

If yes, what is the age of the person?

Enter the age of the person you care for.

What is their vision condition/disease?

Provide the vision condition of the person.

What treatments are you taking for your vision condition?

What is one thing you want others to know about living with your disease? *

Please share your story *

Please share your story as a patient or a caregiver to help others understand your unique journey. You can include getting your diagnosis, telling others, finding support, how you cope with living with the condition, etc.

Upload a Video

Upload a video related to your story (optional).

Do we have permission to share your story?

Do we have permission to share your story? (Read Consent).

How would you like your name to be listed with your story?

If yes, how would you like your name to be listed with your story?

Can we contact you for in-person or virtual speaking engagements? *

If yes, please indicate topics for which you can share your story:

Select topics you can facilitate or speak on.

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Would you be willing to share your story to help amplify advocacy efforts? *

Are you interested in/willing to participate in advocacy activities? *

Are you willing to attend meetings and share your story with Members of Congress? *