Share Your Story

Tell Us Why Vaccination is Important to You*

I want to share a personal story about being impacted by a vaccine-preventable disease.
I want to share a story about why I personally choose to vaccinate.

Name of affected individual:*

First Last

Full name and relationship of individual sharing the story? (e.g., self, mother, brother)*

Age at time of illness*

Please enter a number from 0 to 150.

Type of illness/disease?*

If other, please specify here:*

Loss or survivor?*

Loss (death)
Survivor

Month and year of illness/death? (e.g., Jan. 2020)*

Your full name:*

First Last

Place of residence:*

City State / Province / Region ZIP / Postal Code Country

Email*

How would you categorize yourself? (check all that apply)*

Adolescent (12 - 18 years old)
Young adult (19 - 25 years old)
Adult (26 - 64 years old)
Older adult (65+ years old)
Parent with child(ren) under 19 years old
Pregnant or postpartum person
I prefer not to answer
Other

If other, please specify here:*

Who are you? (select all that apply)*

A person who has been personally impacted by a vaccine-preventable disease
A person who has been positively impacted by vaccination
A person who just wants to share why I think vaccination is so important

Are you looking to raise awareness about a specific disease or vaccine? (check all that apply)*

If other, please specify here:*

Why do you think vaccination is important? Do you have a specific story that you'd like to share related to vaccination?*

What advice would you give to someone who didn't want to vaccinate themselves or their family? What do you want others to know?

Is there anything else you'd like to share?

Describe yourself/your loved one on a personal level, e.g., what are/were your/their personality traits and/or interests?*

What are some of the things that you/your loved one enjoyed doing prior to your/their illness (e.g., recreational activities)? If you experienced the loss of a loved one, what will you miss doing with them the most?*

Did you/your loved one have any chronic or acute medical conditions prior to the illness (e.g., diabetes, cancer, asthma)? Explain, as needed.*

How did you/your loved one become sick? How were you/they acting or feeling? How and when did you/they get diagnosed?*

How did your/their illness progress? At what point did you/they realize it was serious?*

If you/they were hospitalized, what was your experience while in the hospital (e.g., medical complications, specific procedures)? How long were you/they hospitalized? (Enter N/A if not applicable.)*

Were you/your loved one vaccinated? If not, what were the reasons that kept you/your loved one from being vaccinated?*

What do you/your loved one want others to know about the vaccine-preventable disease that you didn't realize until after your/their illness? What advice would you give to others (e.g., what would you say to someone who chose not to get vaccinated)?*

Are you/your loved one suffering any long-term medical complications as a result of your/their illness? Explain, as appropriate.

Is there anything else you'd like to share about your/your loved one's experience?

What have you/your loved one(s) done up to this point to raise awareness about vaccine-preventable diseases (e.g., join a local immunization coalition, hold a community event, make a point to talk about vaccination with friends & family)?

Are you interested in learning more about how to become a vaccine advocate and raise awareness in your community?*

Yes
No
Unsure, but willing to explore

I would like to receive communications from Vaccinate Your Family (e.g., newsletters).

Yes
No

Sharing stories is an important way to educate others about the seriousness of vaccine-preventable diseases. I hereby grant permission to Vaccinate Your Family to use my story and any accompanying photographs and/or videos that I may provide. I agree that I have the rights to grant Vaccinate Your Family the permission to use my/my loved one's story. These uses may include, but are not limited to, videos, publications, advertisements, news releases, websites, social media, and any promotional or educational materials in any medium. I acknowledge that I reserve the right to review my/my loved one's story for accuracy before it is published on the Vaccinate Your Family website.*

Yes
No
I want to discuss this further with a Vaccinate Your Family Representative

Sharing why you vaccinate is a great way to help lift up the importance of vaccination in our communities. I hereby grant permission to Vaccinate Your Family to use this content to develop my story, and any accompanying photographs and/or videos that I may provide. I agree that I have the rights to grant Vaccinate Your Family the permission to use my story. These uses may include, but are not limited to, videos, publications, advertisements, news releases, websites, social media, and any promotional or educational materials in any medium.*

Yes
No
I want to discuss this further with a Vaccinate Your Family Representative

Please upload at least two photos that we can use as part of your story.*

Drop files here or

Max. file size: 50 MB.

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