LLS Financial Assistance Programs
LLS Patient Financial Assistance Programs

Contact Information

I am a: (check all that apply) *
LLS Assistance Received (check all that apply) *

Story Details

Browse to choose your image then click the Upload button to attach it.
  • Digital camera (or cell phone) photos provide best quality.
  • Headshots or individual patient photos are preferred
  • Upload your videos to You Tube and provide the corresponding link

LLS Region

Media Participation and Story Submission Consent and Release

Please sign below to indicate your acceptance of the following terms regarding the use by The Leukemia & Lymphoma Society ("LLS”) of any photographs, video or audio recordings and/or written submissions/stories (collectively "Works") in which you may be included or which you may have submitted to LLS. Please note that all of those present in any photo, video, audio recording or other media submitted to LLS must sign this Consent and Release Form.

You hereby consent to the use by LLS of photographs, videos and/or audio recordings in any and all media, of your voice, actions, likeness, name, appearance (collectively, "Likeness") and the identification of you as an individual with a blood-related cancer, if applicable. You hereby grant LLS a perpetual, non-exclusive, worldwide, royalty-free sub-licensable right and license to use your Likeness in any and all media in connection with the activities of LLS. You agree that LLS may use all or any part of your Likeness and may re-size or crop images to fit format needs.

If you submitted a story, you acknowledge that it may be used by LLS in all print and electronic media, in any language, without time limitation. You warrant that you are the sole owner of all the rights to the story, and have the authority to grant the rights, that the story is your original work, and that the story does not infringe or violate any copyright, right of privacy or publicity, or any other right of any third party, or contain any matter that is libelous or otherwise in contravention of the law.
You hereby release LLS and its authorized agents and assigns and any designee (including any agency, client, broadcaster, periodical or other publication) from any and all claims arising from the use of your Works. You understand that you will receive no payment for the use of your Works. This Agreement will be governed by New York law.
By selecting yes, you represent that you are at least 18 years old and are signing on your own behalf. *