Time=Lives™ Media Submission Form

Submit a video or photo of your story - about a battle with disease, the impact of medical research on your life, or just your thoughts on why it should be a national priority. It doesn't have to be high tech - a photo with a quote is an easy and powerful way to let your voice be heard.

Submissions will go through an internal review process and, if approved, may be posted on any of the "Campaign Properties," which include the FasterCures' Time=Lives web site, YouTube channel, Facebook page, or twitter account. FasterCures will seek your express permission for any use beyond the Time=Lives campaign and will not share your email address or contact information with other organizations.

* Email
* First Name
* Last Name
 Suffix
 Affiliation
* I am a Patient
Family member
Researcher
Scientist
Industry Professional
Investor
Advocate
Other
 City
 State
 Zip
* Whose story are you sharing? My own
  My family member's
  My friend's
 

 I confirm that if I am telling the story of or sharing information about a third party (e.g. a family member or friend), I have received permission from that third party to tell publicly his/her story and share publicly his/her information.
 Why does medical research matter to you?
Maximum characters: 2000
 How has disease impacted your life?
Maximum characters: 2000
 Why is it important that medical research be a national priority in 2013?
Maximum characters: 2000
 Is there anything else about yourself or your story you'd like to share?
Maximum characters: 2000
* Give us a short background on your story:
Maximum characters: 2500
Provide a link to your YouTube video here:
Upload your photo here:
* I have read and accept these terms of use (MANDATORY IN ORDER TO SUBMIT)
*   = Required Field