Submit Your Health Care Story

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Your Personal Story is Needed for Health Care!

Take a stand for Health Care Reform by sharing your health care story

Yes!

Yes, I want to be a health care activist and receive alerts, information, and invitations to participate!

Name

Title

First Name *

Last Name *

Suffix

Address

Address 1 *

Address 2

City

State / Province / Region

Postal Code

Country

Phone Number

- ###

#### *

E-Mail Address

@ *

IHSS Provider?

I’m an IHSS Provider

Yes, I’d like to register to vote.

Join the COPE program?

Yes, I’m a care provider and would like to join the COPE program.

My Health Care Story

Please share your story below and accept the Authorization and Release terms.

Yes, I want to share my healthcare story!

Share Your Health Care Story

Think about yourself, your family, and your friends. What problems have you experienced getting the care you need, or what worries or concerns do you have? How would having access to quality, affordable health care change your life or the lives of your loved ones? Write your story here:

AUTHORIZATION AND RELEASE

By checking "Accept" and submitting this form, I authorize Service Employees International Union, its locals and affiliates (the “Union”), to use and publish in any format, “My Personal Story,” my name, photograph, video, and any other relevant information I provide as part of this campaign. I release the Union from all liability any injury or claim I may have arising from the Union’s publication and use of such material. I am at least 18 years of age, and, to the best of my knowledge, all the information I have provided for this campaign is true and accurate.