MRF Spokesperson Personal Story Prompts

About Me

Thank you for your willingness to share your personal story with members of the media to help raise awareness of melanoma and the importance of sun safety. Please complete the following questions to help us better understand your experience with melanoma.

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* 1. Please provide your full name, occupation and age:

Name:

Occupation:

Age:

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* 2. What is your city and state of residence?

City/Town:

State:

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* 3. Please provide your contact information should a media request arise:

Daytime phone:

Mobile phone:

Email:

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* 4. Would you be willing to share your full name and a recent photo of you and/or your scar (if applicable) with a reporter?

I am willing to share my name only

I am willing to share my name and photo

I am not comfortable sharing any of this information