Share your Story

Have you faced challenges when trying to get a vaccine?

 

Getting the vaccines you need shouldn’t be complicated — but sometimes it is.

Have you ever had trouble getting a vaccine? Maybe you couldn’t find it, weren’t sure if you needed a prescription, didn’t know if it was recommended for you, or had problems with insurance.

We want to hear your story.

    Tell us a bit about your experience*

    What happened when you tried to get vaccinated? What were the barriers or challenges you faced along the way? Take as many or as few words as you need.

    What is your name?*

    We won’t publish it unless we contact you first.

    Where do you live?*

    City, State

    What is your email address?*

    A team member may contact you to follow up.

    What is your phone number?

    Optional – if you’d prefer to be contacted by phone instead of email.

    Submission terms*

    By submitting below, you agree to the personal consent and release terms.

    Additional acknowledgment*

    I understand that once my information is disclosed, it may no longer be protected under HIPAA, and there is a risk it may be re-disclosed.

    Age confirmation*

    Signature (type your full name)*

    Date*

    IMPORTANT NOTICE TO PATIENT STORY/TESTIMONIAL PARTICIPANTS.

    Please read this personal consent and release (“Consent”) carefully before agreeing to its terms and participating in the “Patient Story” interview (“Interview”) and testimonial (“Testimonial”). This is a legal and binding contract between you and VACCINATE YOUR FAMILY (“VYF”). This Consent contains information related to the use, disclosure, and ownership of your story, images, and other information you provide to VYF and your participation in the Interview/Testimonial. These stories are being collected in order to inform the dialogue around public health and to encourage policymakers to ensure access to vaccines. By participating in the Interview/Testimonial, you acknowledge that you understand and agree to be bound by the terms set forth in this Consent. If you do not agree to the terms of this Consent you will not be authorized to participate in the Interview/Testimonial.

    By submitting this Consent, I grant VYF the permission to use my story/photo/video, including the disclosure of my health information if applicable, on the public campaign website viraltruths.org and for promotional purposes and anywhere where VYF deems. I further agree VYF may use, and grant others the right to use, my filmed and/or recorded image, likeness, voice and/or name (if consent for name is given), without limitation or restriction, and without payment of any kind, for all purposes, in and in connection with this or any other production, throughout the universe, in perpetuity, in any and all languages, formats, manner, media, devices, processes and technologies, now known and later devised. Copyright and all other rights in and to the recording will be owned by VYF. I understand that my story/photo/video will also be accessible from and searchable on the Internet.

    I understand that this authorization is voluntary and that I may refuse to submit this authorization.

    I understand that this use potentially discloses personal health information, as covered in my testimonial. I understand that VYF is not a health care provider. I understand that once disclosed, my health information may be subject to re-disclosure, at which point it is no longer subject to federal privacy laws, such as HIPAA. Therefore, I also understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not submit this Consent.

    I waive any right to inspect or approve VYF’s raw recording of my voice and image, or the materials it creates using my recorded voice and image or containing my name. I release VYF from any and all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, and any other claim related to its use of my recorded voice and image—including but not limited to claims related to blurring, distortion, alteration, optical illusion, digital alteration, use in composite form, whether intentional or otherwise, that may occur or result from its use or publication of my recorded image and voice.

    I represent and warrant that: (1) I am at least 18 years old. (2) I have not granted any other person or entity an exclusive license over my voice and/or image. (3) No other person or entity’s authorization or consent is required for me to agree to and execute this Release and Consent.

    I have read this release and consent, understand it, agree to it, intend to be legally bound, and submit this form of my own free will. I understand that is VYF will proceed in reliance on my consent. If I do not wish to give such consent, I will not submit this form.