ASH1L WARRIOR STORY

Story Author Details *

First Name Last Name

Email *

example@example.com

Your relationship with ASH1L Warrior *

Self Biological Parent Guardian Patient Advocate Caregiver Medical Advisor Other

ASH1L Warrior Name *

First Name Last Name

ASH1L Warrior Date of Birth *

Date

Country *

Write your story here *

If you have submitted the story or would like to submit it through email, then kindly type in N/A in the area provided. The email address to email your story is info@care4ash1l.com

Please upload any photos and videos you like to share *

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Do you give Care4ASH1L the permission to publish your story, photos and videos on social media - Facebook, Twitter, LinkedIn, Instagram, Care4ASH1L website and other awareness as well as fundraising campaigns? *

Yes No

Permission to publish - By selecting "YES" you are agreeing to the terms and conditions to submit your story, photo(s) and video(s). By clicking "YES", you grant Care4ASH1L permission to use your story, photo(s), video(s), name, age, gender and country on our website, and as part of our ongoing programs to increase rare disease awareness. By selecting "YES", you hereby grant permission to Care4ASH1L and its agents or employees to use your ASH1L Warrior’s story, photo(s) and/or video(s) for publication in brochures, newsletters, display boards, social media accounts, and websites without notifying you. You acknowledge that Care4ASH1L may choose not to use the story, photo(s), video(s) at this time, but may do so at its own discretion at a later date. You agree that Care4ASH1L reserves the right to discontinue use of photos without notice. Should you ever decide to discontinue or revoke your story and/or photos and/or videos from social media then you can email info@care4ash1l.com about the removal of content. Care4ASH1L will eliminate and remove your story, photos and videos from their official website, YouTube, and any future campaigns as well as posters. However, any previously published data (including story, photos and videos) used for campaigns cannot be removed including the posters. The new or future campaigns and posters will not have your data (including story, photos and videos) included. By clicking "YES", you agree that you have read this release before submitting and that you fully understand the contents, meaning, and impact of this release. *

Yes