Thank you for your interest in participating in #SpeakUpSC week. Your story matters. Through story-telling, we will take steps to ensure that the injustices occurred once will not happen again. We are currently seeking individuals with diverse stories to share during #SpeakUpSC week. You have been nominated as a person who can contribute to the solution. Participation is completely voluntary. If you would like to share your story of injury, injustice, and/or malpractice related to the CV-19 response,  please answer the questions below and acknowledge the waiver. Only those who complete this form in its entirety will be considered. We genuinely appreciate you taking the time to share your story and be a part of the solution.

In coordination with the Spartanburg Christian Action Network, we will be conducting local interviews on site in Spartanburg on September 15, 2023 between 10:30am and 2:30pm. Interviews will take place at Legacy SC, 3700 S Church St Ext, Roebuck, SC 29376

Media Release Waiver: By checking below I hereby grant the South Carolina Health Rights Cooperative, the Spartanburg Christian Action Network and Legacy SC permission to use my written and/or video testimony, or other digital media (“photo”) in any and all of its publications, including web-based publications and social media campaigns, without payment or other consideration .I understand and agree that all media will become the property of the above named organizations and will not be returned. I hereby irrevocably authorize the above named organizations to edit, alter, copy, exhibit, publish, or distribute these forms of media for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the media.I hereby hold harmless, release, and forever discharge the above named organizations from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization .I HAVE READ AND UNDERSTAND THE ABOVE MEDIA RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE. I INDICATE MY ACCEPTANCE BY SIGNING BELOW.