TELL US YOUR STORY!

Let us know how our financial assistance program(s)

have helped you or someone you care for.

Please note if you are looking for financial assistance or have questions on how to apply for a program

please contact our Information Resource Center at (800)-955-4572

Story Details

Please include details about the expenses we helped pay for. Don’t forget to include a high-resolution picture
of yourself or feel free to upload a video. *

Photo/Image

Video

When uploading a picture or video please remember these few things:

Digital camera (or cell phone) photos provide best quality.
Headshots or individual patient photos without logos or branding are preferred
Upload your videos to You Tube and provide the corresponding link

Contact Information

First Name *

Last Name *

Email Address *

Phone Number *

City *

State *

Zip Code *

I am a: *

Please select the assistance you have received from LLS : (select all that apply) *

Photography, Media Participation and Story Submission Consent and Release

Please read and sign below to indicate your acceptance of the following terms regarding the use by The Leukemia & Lymphoma Society, Inc. ("LLS") of any photographs, video, podcast or audio recordings or works, written submissions, stories, graphic, musical or choreographic works (collectively "Works") in which you may be included or which you may have submitted to LLS:

You hereby warrant and represent that you are the sole owner and/or author of the Works, and that you have the exclusive right and authority to submit the Works to LLS upon the terms and conditions stated herein.

You hereby consent to the use by LLS of photographs, videos, podcasts, audio recordings or other Works in any and all media, of your voice, actions, likeness, name, appearance (collectively, "Likeness"). You hereby grant LLS a perpetual, non-exclusive, worldwide, royalty-free, sub-licensable right and license to use your Likeness and Works 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 or audio to fit format needs. You understand that your Likeness and Works may also be used by third parties that LLS works with, as well as LLS's outside consultants, vendors, sponsors, advisors, and agents (collectively "LLS Representatives") for use in films, videos, news stories and broadcasts, as well as letters, e-mails, print publications, internet/social media posts and other publications for education, fundraising or public awareness.

You hereby release, discharge and hold harmless LLS, LLS Representatives, and their assigns and designees (including, but not limited to, any agency, client, broadcaster, periodical or other publication) from any and all claims arising from the use of your Works or Likeness. You understand that you will receive no payment for the use of your Works or Likeness. This Agreement will be governed by New York law. You agree that you have no claim (including, without limitation, claims based upon invasion of privacy, defamation, or right of publicity) arising out of or in connection with, any use, alteration, or use in any composite form hereunder of your Work or Likeness in connection with the activities of LLS. You hereby warrant and represent that you have the right to enter into this agreement and to grant the rights granted to LLS herein.

I agree to the terms of the Photography, Media Participation and Story Submission Consent and Release *

Yes - I represent that I am at least 18 years old and I am signing on my own behalf.

Yes - I affirm that I am the parent or legal guardian of a child under the age of 18 years old, appearing in any photo, video, audio or other media and/or who has submitted his/her story to LLS and that I have the legal right to consent to, and by signing below, I hereby do consent to, the terms and conditions of this Consent and Release.