Patient Submission Form

Disclaimer: The purpose of collecting these stories is for the use in SRS activities, i.e. website, film, brochures, posters, published literature materials, newsletters, philanthropy materials and other venues as appropriate. In addition, these stories could be used in SRS publications, in public service ads, or in patient advocacy activities. Not all stories submitted will be accepted and posted on the website or in other forms of media. SRS will not accept any patient stories that have already been copyrighted, told through the form of newspapers, magazines or with the assistance of hospital websites etc.

Patient:

Name*: 

Address*: 

City*: 

State*: 

ZIP:    

Condition:    

Occupation: 

Orthopaedic Surgeon:

Name*:     

Address*: 

City*: 

State*: 

ZIP*: 

Phone*: 

Fax:      

Email: 

Please submit attached to your submission form the following:

Your story written in digital format
Before and after pictures
Any other materials that help illustrate your story, video, poetry, photographs etc.

Optional questions to consider when writing your story:

• How did you find out you had scoliosis?
• What was your treatment plan?
• How has the outcome of your treatment affected your life?
• What do you wish you knew about scoliosis before you were diagnosed?

Remember to include any extra pages of description, videos, background, photos, etc.

Upload Your Story (as a .docx or .pdf):

Additional Files and Images:

Photo/Video Release Form

By completing and signing this form, I hereby grant and authorize the Scoliosis Research Society the right to take, edit, alter, copy, exhibit, publish, distribute, and make use of any and all pictures or video taken of me or submitted by me to be used in and/or for promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits, and submissions to journalists, websites, social networking sites, and other print and digital communications. This authorization extends to all languages, media, formats, and markets now known or hereafter devised. This release is a perpetual, irrevocable license authorized as a charitable contribution in furtherance of non-for-profit educational, research, and advocacy activity.

I understand and agree that these materials shall become the property of the Scoliosis Research Society and will not be returned.

I hereby release the Scoliosis Research Society from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

I certify I am 18 years of age or older and that I am competent to contract in my own name.

I certify I am 17 years of age or younger and my parent or guardian has completed the information below.

I have read this release before signing below and I fully understand the contents, meaning, and impact of this release.

Signature of Participant/Patient:           Date:

If the person signing is under the age of consent, then this release must be signed by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual

Signature of Guardian:                          Date: 

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Milwaukee, WI 53202
Fax: (414) 276-3349
Email: info@srs.org