Share your story!

Share your story!

Your bravery, strength, and love inspires all of us at StudentsCare. Thank you for opening your heart and allowing our StudentsCare to be a part of your story.

Name Your connection with StudentsCare Pediatric participant (age 16+)
Parent/Guardian of pediatric participant
Older adult participant
Caregiver/Family member of older adult participant
Student Buddy
Other
If you select the "Other" option, please enter your connection below Phone Email Participant's First Name (If participant is not the one filling out this form) Please share about your experience with StudentsCare! Submission Agreement I agree by submitting an entry to be featured in StudentsCare's “Share Your Story”, I, (either for myself as an individual age 18 or older, or on behalf of my minor child, as parent or legal guardian) expressly authorize StudentsCare to use any protected health information (“PHI”) included in my submission on its websites, social networking, or social media platforms; for presentations to supporters; in brochures, direct mail, or other marketing material. I also waive, for myself and my heirs and assigns, any and all intellectual property rights to the contents of the submission, in part or whole, and I agree that upon receipt, StudentsCare becomes the sole owner of any intellectual property derived from the submission.I understand and agree that the PHI included in the submission will no longer be protected by HIPAA and the Privacy Rule. I understand that other individuals may find my story helpful and may share it with others in print or on the internet, and I agree that StudentsCare has no responsibility or liability for any re-disclosure of my PHI included in the submission. I understand that I have the right to revoke my authorization herein at any time by sending a written request to StudentsCare and that my decision to revoke the authorization does not apply to any disclosures or distribution that may have taken place prior to the date my request to revoke is received by StudentsCare.