Stories of Hope Content Collection (Neurocritical Care Providers)

A few reminders as you are submitting your Story of Hope:

Please do not use a patient name, unless they have provided a consent form
Please do not submit any patient photos, unless they have signed a photo release form
Please do not use your institution name, unless they have granted you explicit permission to mention them within your story

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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; If a patient is referenced by name, we need a release form completed.

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* 5. Upload any photos associated with your story.

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

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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?

Yes

No

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

Yes

No

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* 8. I 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 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. I confirm that no proprietary or identifiable patient information is contained in the Submission.

Yes

No