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Long COVID Campaign - Candidate Form

Help raise awareness of Long COVID and the importance of COVID-19 vaccination.

Resolve to Save Lives (Resolve), a non-profit public health organization, is looking for Long COVID patients between the ages of 18-29 who want to share their stories! They are teaming up with state and local health departments to develop a media campaign to raise awareness of Long COVID and the importance of getting vaccinated, which will launch during Fall 2021.

Patients featured in the campaign will participate in a few brief preparatory calls and one day of filming within their preferred location – no travel will be required. They will be compensated $2,500 for their time.

If you are interested and think you would be a strong candidate to participate in the campaign, please fill out this survey and we will be in touch.
1.Name(Required.)
2.Contact information(Required.)
3.Are you between the ages of 18 -29?(Required.)
4.Are you fully vaccinated against COVID-19 (received the one-dose J&J vaccine or two doses of the Pfizer or Moderna vaccine)?(Required.)
5.Have you had a confirmed case of COVID-19 either via test or a physician’s assessment?(Required.)
6.Are you experiencing any of the following symptoms on a persistent basis, at least 12 weeks after being diagnosed with COVID-19 (check all that apply)(Required.)
7.In which city and state do you live?(Required.)
8.What is your race/ethnicity? (select all that apply)(Required.)
9.Please provide a brief summary of your experience with long COVID.(Required.)
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