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Help Us Help others:
please share your personal story!

Are you interested in sharing your story about how pancreatic cancer has touched you?  The stories help provide inspiration to those who have been recently diagnosed, raise awareness about the disease, and  demonstrate how people can get involved in their communities.*

  *indicates required field
*First Name:
*Last Name:
*Address:
*City:
*State: *Zip:
Country:
*Primary Phone: Work: Home: Cell:
Secondary Phone: Work: Home: Cell:
*Email:
 
*I am a (please check all that apply):
 
Patient
Researcher
Volunteer		 Caregiver
Health Professional
Family Member/ Friend of a Patient
*How Pancreatic Cancer has touched me (please limit to 650 words):
 
If this story is about diagnosis and treatment, please provide as much of the following information as possible:
Age of Patient at Diagnosis:                Date of Diagnosis: 
(mm/dd/yyyy)     
Diagnosis:

Submit a photo to go with your story. Submitting a photo is a requirement in order for the Pancreatic Cancer Action Network to consider your story for placement on our website and/or in other communication or promotional materials.

By submitting this I agree that the Pancreatic Cancer Action Network may post my story and photo on the Pancreatic Cancer Action Network website, newsletter and/or other promotional materials.
All stories are subject to review and editing by the Pancreatic Cancer Action Network . Only select stories will appear on the Pancreatic Cancer Action Network website.

*The Pancreatic Cancer Action Network will not sell, trade, or rent your personally identifiable information to third parties. Our full privacy policy can be found at www.pancan.org/section_privacy_legal/privacy_policy.php


 
  

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