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* 1. Please provide your full legal name:

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* 2. Please provide your preferred telephone number:

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* 3. Please provide your preferred email address:

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* 4. Can you give us a 300-500 word Story of Hope to share/promote.

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* 5. Upload any photos associated with your story.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 6. Would you be willing to sit in front of a phone and provide a 60-90 second video about your story?

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* 7. Would you be willing to record a podcast episode?

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* 8. I (a patient or guardian for the minor patient identified) have submitted a video, photograph, testimonial, or similar item to be used by The Neurocritical Care Society, Inc. and the Neurocritical Care Foundation (collectively “NCS”) in connection with its business, including for use in advertising, marketing, and other commercial purposes (the “Submission).  I hereby grant to NCS and its designees the right to use my (or the minor patient identified) name, likeness, photograph, image, video, voice, statements, and audiovisual recording as included in my Submission for any purpose, including a commercial purpose, in any form or medium, including, but not limited to online, website, social media, print, public display, and email.  I, as the sole owner of the rights in the Submission, assign to NCS all rights in the Submission, including the copyright.  I hereby release NCS and its designees from any and all claims and liability related to the use of the Submission.  By this authorization, I authorize NCS to use my protected health information (“PHI”) as I have included in the Submission.  I understand that I may revoke the authorization to use my PHI at any time, provided that I submit to NCS a signed revocation form.  However, this revocation shall not apply to the extent that NCS has taken action in reliance on this authorization prior to revocation.

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