PR/Video Consent Form

I Want to Tell My Sickle Cell Story!

Thank you for your interest in sharing your story with the Sickle Cell Disease Association of America. We have a variety of opportunities for you to stand up and speak out about your experiences with sickle cell, including but not limited to press and media interviews, social media spotlights, video appearances and blog mentions. Please share your information below and we will reach out to you with more. For questions or concerns, please reach out to eday@sicklecelldisease.org.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age Range

18-2930-4950+
Date of Birth *

MonthDayYear
Date
I am a sickle cell...*

WarriorCaregiverParentSpouse/partner/family memberMedical providerResearcherCHWOther
I am comfortable...

Being interviewed by a reporter for a print or web articleBeing interviewed on camera for SCDAA videosBeing interviewed by a reporter on cameraHaving my story highlighted on social media/on the SCDAA websiteHaving my quote/picture used in SCDAA marketing materialsUsing my social media reach to share SCDAA news, events, initiativesAll of the above
I can speak about:

Clinical trialsGene Therapy (participant)Gene Therapy (considering participating)Mental HealthEmergency room experiencesCaregivingAdvocacyStigmaPain crisesTransition from pediatric to adult careTransfusions/Blood Donation Importance
Any other topics you would like to speak to?
Tell us anything about yourself you want us to know:
Should be Empty:

I Want to Tell My Sickle Cell Story!