Thank you for participating in the campaign to ensure health care coverage for people with disabilities. Please fill out this form to submit your video for consideration to be included in Rooted in Rights' #IAmAPreexistingCondition YouTube playlist or another video in the campaign. Submitting your video does not guarantee publication. If this submission form is inaccessible to you, links for videos uploaded to YouTube can also be sent to info@rootedinrights.org.
Email address *
Instructions for creating your video
To create a submission for consideration, please use the following script. You can speak it, hold up signs, or use any manner accessible to you so long as you keep to the script:

· “My name is ________________________.”
· “I’m from ___________________________.”
(Where do you live?)
· “I have ______________________________.”
(State your preexisting condition(s).)
· “Without healthcare coverage for preexisting conditions, I ___________________.”
(What treatments or care would you not be able to receive without healthcare coverage for your preexisting conditions?)
· “Because of this, I would tell my legislators ________________.”
(What do you want your senators to know? i.e., vote no on the American Health Care Act, protect the lives of millions of people with preexisting conditions.)
· Please pause for a moment after saying what you would tell your senators and end your video with the following: “I am a preexisting condition.”

Once your video is complete, please upload the video to YouTube and include the link to the uploaded video in the form below. **Make sure your video is Public or Unlisted, or we will not be able to access it.
Example Video Submission
Full Name (How do you want to be credited?) *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Your video submission YouTube URL *
Your answer
Please Read the Release Form Below
Rooted in Rights
Materials Release Form

Description of “Material”: Video Submission for the #IAmAPreExistingCondition Video

This Agreement shall confirm that:
A) I grant Disability Rights Washington d/b/a Rooted in Rights (“Rooted in Rights”) an irrevocable, non-exclusive license to use, release, exhibit, depict, display, reproduce and broadcast the Material, and recordings of my likeness and voice on a video, audio, photographic, digital, electronic or any other medium and to use my name in connection with these recordings;
B) I represent and warrant that the Material was created and/or is owned by me and that the Material is original; that I am the sole owner of all rights in and to the Material; that I have obtained all rights, consents and permissions necessary regarding the content of the Material and the Material (including, but not limited to, rights of any party appearing in the Material);
C) I hereby release Rooted in Rights from any claims, whether existing at present or in the future, including, without limitation, all rights, demands and/or liabilities regarding invasion of privacy, right of publicity, defamation (including libel and slander), copyright infringement, moral rights, confidentiality, and/or any other personal or property interests or rights of the Material and any ancillary and subsidiary uses of the Material;
D) If any controversy or claim arising out of or relating to this Agreement, or the breach of any term hereof, cannot be settled through direct discussions, the parties agree to endeavor first to settle the controversy or claim by mediation conducted in the State of Washington and administered by an experienced mediator.

I hereby release Rooted in Rights from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I may hereafter have from liability for any violation of any personal or proprietary right I may have in connection with such use of my Material in any medium. I have read and fully understand the terms of this release.

I have read and fully understand the terms of this release. *
A copy of your responses will be emailed to the address you provided.
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