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Contact Information
* Required Fields
Only the First Name, State, and Story will be shared on the website.
I am a:* patient
caregiver
healthcare provider
Prefix:
First Name:*
Last Name:*
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*
Email Address:
Daytime Phone:
Home Phone:
(If different from Daytime Phone)

Caregivers' Information
Caregiver Gender:*  Female  Male
Caregiver Age:
I am caring for my:
Patient's Age:

Permission Statements
I give permission for the AGS Foundation For Health in Aging to add my story to its story database and use it for legislative, educational and media purposes to help all older adults.
I am willing to speak to newspaper or magazine reporters about my story.
I am willing to speak to radio and television reporters about my story.
I would like to be part of an action alert team when emails need to be sent to state or federal legislators.

Instructions
1. Stories should be no more than 500 words, written in first person. Three sample stories are included for your information.
2. Begin with a brief paragraph or two about your situation. Please include:
  • Your first name, and if you are writing as a caregiver, your loved one's first name and your relationship
  • Your age and sex (or your loved one's age)
  • Your care recipient's condition (i.e. Alzheimer's Disease, Spinal Cord Injury)
  • Tell the specifics about your situation and your experience with a geriatrics health care provider. (i.e. whether or not you receive help-- paid or unpaid, your concerns and fears, the positive aspects of your experience as well as your frustrations).
Enter your story here: