Did you Heart disease in women Center and wind up healthier and happier? Tell us about it! Your story can help motivate and inspire other women to get moving on the path to lifelong heart health.

To submit your story, please complete the form below. Be sure to read the consent and release before submitting your information. If your story is selected for publishing on our Web site, we will need to collect your first and last name and city to identify your story, as well as your e-mail address so that we may notify you.

You also can check the preference box following the consent and release form below to receive periodic news and updates about women's heart health. By submitting your information, you agree that it will be governed by our Privacy Policy.

First Name:*

Last Name:*

City:*

State:*

ZIP Code:*

E-mail:*

Repeat E-mail:*

Story Title:*

Your Story: (300 words or less)*

* To the best of my knowledge, I acknowledge that all the information I have provided in the above form is correct.

Consent and Release

I hereby agree that the American Heart Association and its Heart disease in women Center program may use my written personal physical activity experience. I further agree and consent to allow the American Heart Association and Heart disease in women Center and/or its affiliated causes to use, amend, transfer, display, broadcast, reproduce and/or distribute publicly or otherwise any such written case studies, (hereinafter collectively referred to as "patient testimonial") for any purposes whatsoever, including, but not limited to, educational, promotional or commercial purposes.

The American Heart Association and Heart disease in women Center may at its/their sole discretion make any and all changes in, additions to, and deletions from the "patient testimonial." Such alterations include, but are not limited to cuts, edits, additions, changes, rearrangement, adaptation of the "patient testimonial" to different formats, and other changes, additions and deletions necessary to make the "patient testimonial" commercially viable. With reference to the alterations referred to above, I hereby waive any and all claims I may now or hereafter have to the rights of integrity, disclosure and withdrawal and any other rights that may be known as or referred to as "moral rights."

The American Heart Association and Heart disease in women Center may use the "patient testimonial" without limitation in time, without stating my name insofar as such use, to the extent required by the American Heart Association and/or Heart disease in women Center is related to educational, sales, promotional or marketing purposes.

This agreement contains the full terms of release intended by the parties and may not be changed except in writing signed by both parties to this agreement.

* I agree to the terms of the Consent and Release.

* required fields

Get a friend to Heart disease in women Center!>>