Share your story!
To our buddies, young and old, your bravery, strength, and love inspires all of us at StudentsCare and keeps us working hard to help more kids and seniors through difficult times. Thank you for opening your heart and allowing our students to be a part of your story.
Your Name
Your connection with StudentsCare
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Phone
Email
Do you wish to receive email updates about our program?
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Participant's First Name (If participant is not the one filling out this form)
Participant's Hospital/Facility
Did participant receive in-person or virtual services from StudentsCare?
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Please share about your experience with a StudentsCare buddy!
Do you have any photos you wish to share? Please email them to tami@students-care.org
Submission Agreement
By submitting an entry to be featured in StudentsCare's “Share Your Story”, I, (either for myself as an individual age 18 or older, or on behalf of my minor child, as parent or legal guardian) expressly authorize StudentsCare to use any protected health information (“PHI”) included in my submission on its websites, social networking, or social media platforms; for presentations to supporters; in brochures, direct mail, or other marketing material. I also waive, for myself and my heirs and assigns, any and all intellectual property rights to the contents of the submission, in part or whole, and I agree that upon receipt, StudentsCare becomes the sole owner of any intellectual property derived from the submission.I understand and agree that the PHI included in the submission will no longer be protected by HIPAA and the Privacy Rule. I understand that other individuals may find my story helpful and may share it with others in print or on the internet, and I agree that StudentsCare has no responsibility or liability for any re-disclosure of my PHI included in the submission. I understand that I have the right to revoke my authorization herein at any time by sending a written request to StudentsCare and that my decision to revoke the authorization does not apply to any disclosures or distribution that may have taken place prior to the date my request to revoke is received by StudentsCare.
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