EmailMe Form - Submit your story

Name *

First Last

Email *

Phone *

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Is this story about: *

When were you or your loved one diagnosed? *

How old were you or your loved one when you/they were diagnosed? *

What brain tumour type do you or your loved one have (if known)?

What's the grade of your/their tumour (if known)?

Low grade (1-2)

High grade (3-4)

Share a brief synopsis of your story or your loved one's story (You also have the option to share a brief video of your story instead of providing text here, as indicated in the next question.):

(Maximum 600 words)

Upload a short video of your/their story (optional):

It is preferable to record interviews with our content writer to ensure stories are accurate and detailed. Would you consent to having your interview recorded, solely for the purpose of writing your story? *

Yes

No

Would you also consent to having Brain Tumour Foundation of Canada use audio clips from your recorded interview for promotional purposes (for instance, to promote your story on our website or social media channels, or in a promotional video)? *

Yes

No

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Authority to share story and photos/videos/audio clips

I/We, the undersigned, hereby agree to share my/our personal story and photos/videos (and audio clips, if selected above) with Brain Tumour Foundation of Canada (BTFC). I/We understand the story and photos/videos/audio clips may be shared online or offline by BTFC, for use in BTFC's websites, social media platforms, videos, and more.

I/We understand BTFC reserves the right to share my/our story at any time throughout the year, based on how it aligns with other planned initiatives, and that BTFC may also choose not to share my/our story at any point.

I/We acknowledge and agree that we are not entitled to and will not claim any compensation or other payment from BTFC for such publication or use.

I/We understand that BTFC will submit the story to me/us for final approval before it is published.

By submitting this form, you consent to us processing your data, including any sensitive health information about you or your loved one. Your details will be stored securely in our database and will never be shared with other organizations for marketing purposes.

Date: *

MM / DD / YYYY

Electronic signature: *