Your story and health matter. Share your story below, and it could be shared in an upcoming campaign from Healthline Media to spotlight personal experiences of COVID-19.

By sharing your story, you are giving a voice to how not only our communities have been affected but how we have been impacted individually. Thank you for sharing your story with us.

Location*
Health Equity Theme
How would you like your story categorized? *You can select multiple*
Share your lived experience... be as detailed as you'd like, please
Image Upload*
No File Chosen
File uploads may not work on some mobile devices.
Upload an image of yourself, your family or something that helps tell your story

Your Privacy is important to us. Click here to read our Privacy policy

Talent and Image release

I, the undersigned, hereby grant Palette Group, LLC, Healthline Media, Inc., and their licensees, assignees, transferees, and other successors-in-interest (collectively, “Palette Group”), all rights of every kind and character, in perpetuity, irrevocably in and to my performance, appearance, likeness, name, written word, and/or voice (the “Performance”) in connection with the submission, related to the Healthline Media, Inc., “TRANSFORM: HEALTH EQUITY” Campaign. I grant Palette Group the permission to use and publish any written text, photography, footage and understand that Palette Group may have unrestricted use of these for whatever purpose, including advertising, with any retouching or alteration without restriction.  I give the rights to these written words, photographs and footage to be edited, exhibited, copied, published, and distributed for commercial purposes without any approval or restrictions.  There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be utilized in connection with this Release.  This Release applies to written text, photographs and footage collected as part of the session(s) listed on this document only.  By signing this release I understand this permission signifies that written text, photographs and footage of me may be electronically displayed via the Internet or in a public educational setting and/or to transferred to a third-party, where such use of the Project, or any portion thereof, may include portrayal, discussion or commentary of the Project, including the Performance.  

IN CONSIDERATION OF BEING PERMITTED TO APPEAR IN THE PROJECT, I AGREE TO THE FOLLOWING: I HEREBY RELEASE AND HOLD PALETTE GROUP, ITS DIRECTORS, OFFICERS, EMPLOYEES, AGENTS AND ASSIGNS HARMLESS FROM ALL LIABILITY TO MY AND MY PERSONAL REPRESENTATIVES, ASSIGNS, HEIRS, AND NEXT OF KIN FOR ANY LOSS OR DAMAGE, INCLUDING FROM ANY ALLEGED OR ACTUAL INFRINGEMENT OR VIOLATION BY THE PROJECT UPON ANY RIGHT OF PARTICIPANT AND/OR ANY THIRD PARTY, INCLUDING WITHOUT LIMITATION, ANY PROPRIETARY RIGHT AND/OR INTELLECTUAL PROPERTY RIGHT AND FOREVER GIVES UP ANY CLAIM OR DEMANDS THEREFORE, ON ACCOUNT OF INJURY TO MY PERSON OR PROPERTY, INCLUDING INJURY OF PARTICIPANT, WHETHER CAUSED BY THE ACTIVE OR PASSIVE NEGLIGENCE OF PALETTE GROUP OR  OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW.

Confirm talent and image release*
Use your mouse or finger to draw your signature above
Save and Resume Later
Progress
Powered by Formstack Create your own form