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* 1. Have you been diagnosed with breast cancer?

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* 2. What barriers to care (if any) have you faced in your breast cancer diagnosis?

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* 3. Share your story with us.

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* 4. Please review the following Publicity Release and Waiver. If you agree to the terms, you may electronically accept by typing your name, date, phone number, and email address below.

I give my consent and permission to The Susan G. Komen Breast Cancer Foundation, Inc. d/b/a Susan G. Komen, its affiliates, their sponsors and corporate sponsors, their licensees, successors, and assigns (collectively, “Komen”) the unlimited and irrevocable, perpetual right to use and create derivative works of the following “Materials” for any purpose whatsoever and without compensation to me of any kind: use of my name, nickname, image, likeness, voice, photograph, and biographical information as well as any personal statements, photographs, videos, audiotapes, artwork presentations, and other recordings or depictions of any kind that I make available to Komen, its vendors or partners, or that Komen creates. I acknowledge that the Materials are truthful, accurate, and not misleading.

I hereby acknowledge that Komen is the sole owner of the works it creates using the Materials and that Komen shall have unlimited right throughout the world to copyright, use, reuse, publish, republish, broadcast and otherwise distribute the Materials without compensation to me. I represent that any use of the Materials by Komen will not infringe on copyright, trademark, trade secret, patent or other intellectual property right or any moral right of any third party, such as all radio, network, cable and local television programs, print materials or other format or media (including electronic media) now known or hereafter devised in perpetuity. I expressly release Komen from any and all claims arising out of the use of the Materials.

This Publicity Release and Waiver extends to claims and facts unknown and unsuspected to exist at the time of execution. I, for myself and my next of kin, heirs, administrators and executors, waive and release Komen, its directors, officers, administrators, past and present employees, affiliates, volunteers, agents, and representatives from any and all claims, liabilities, actions, demands, expenses, and attorneys’ fees arising out of Komen’s use of the Materials. I hereby waive any right to inspect or approve Komen’s use of the Materials and any right to receive royalties or other compensation arising from or related to the Materials.

This Publicity Release and Waiver shall be construed under the laws of the State of Texas. In the event any provision of this Publicity Release and Waiver is deemed unenforceable by law, Komen shall have the right to modify such provision to the extent necessary to be deemed enforceable, and all other provisions of this Release shall remain in full force and effect.

By entering my full name and the required fields below, I electronically accept the terms of this Publicity Release and Waiver and intend my acceptance to be a complete and unconditional release to the greatest extent allowed by law. I also certify that I am at least 18 years of age.