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Submit a Survivor Story

Are you interested in sharing your survivor or co-survivor story? If so, please fill out form below. Survivors and co-survivors are always needed to share their story for Komen San Antonio promotions. *Please note, although we appreciate every submitted survivor story, not all will be used*

*1.	Question - Required - First Name
*2.	Question - Required - Last Name
*3.	Question - Required - Please enter the city in which you live.
*4.	Question - Required - Please enter the state in which you live.
*5.	Question - Required - Please enter your phone number.
6.	Question - Not Required - Please provide your e-mail address.
7.	Question - Not Required - What is your ethnic origin?
8.	Question - Not Required - What year was diagnosis?
*9.	Question - Required - May we share this story on our website, with media and other public avenues?
*10.	Question - Required - Please tell us your story:
*11.	Question - Required - Terms for Submitting a Story: By choosing to submit a story on the Komen San Antonio Web site, you acknowledge and agree that any information you provide, including any photo, may be viewed by the general public. You further agree that Komen may use your story and photo in any manner it deems necessary or appropriate. Komen reserves the right to edit, abridge or format stories for any reason and to remove or decline to post any story or photo. Komen does not endorse or make any warranties or representations with regard to the accuracy, completeness or timeliness of any of the statements in your story. By submitting a story, you are agreeing to all of these terms and conditions. If your story is chosen, you will receive an email requesting a photo. I agree and accept the Terms for Submitting a Story*

San Antonio Affiliate of Susan G. Komen for the Cure®
P. O. Box 6678 San Antonio, Texas 78209 · Phone: 210-222-9009 · Fax: 210-222-9766 · Email: info@sakomen.net

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