<p><span style="font-size: medium"><span><span><strong>Tell Us Your Story</strong></span></span></span></p><p><br />* Denotes a required field</p><form action="/HEARTORG/form/thankYou.jsp" name="emailForm"><table cellspacing="6" cellpadding="10" width="100%" align="center"><tbody><tr><td><table cellspacing="6" cellpadding="10" width="100%" align="center"><tbody><tr><td style="text-align: left">*First Name</td><td><input id="required_Name" maxlength="120" size="40" name="Name" type="text" /></td></tr><tr><td style="text-align: left">*Last Name</td><td><input id="required_Last_Name" maxlength="120" size="40" name="Last_Name" type="text" /></td></tr><tr><td style="text-align: left">*City</td><td><input id="required_City" maxlength="120" size="40" name="City" type="text" /></td></tr><tr><td style="text-align: left">*State:</td><td><select id="required_state" input="" name="state"> <option value="AL" selected="selected">AL</option> <option value="AK">AK</option> <option value="AZ">AZ</option> <option value="AR">AR</option> <option value="CA">CA</option> <option value="CO">CO</option> <option value="CT">CT</option> <option value="DE">DE</option> <option value="DC">DC</option> <option value="FL">FL</option> <option value="GA">GA</option> <option value="HI">HI</option> <option value="ID">ID</option> <option value="IL">IL</option> <option value="IN">IN</option> <option value="IA">IA</option> <option value="KS">KS</option> <option value="KY">KY</option> <option value="LA">LA</option> <option value="ME">ME</option> <option value="MD">MD</option> <option value="MA">MA</option> <option value="MI">MI</option> <option value="MN">MN</option> <option value="MS">MS</option> <option value="MO">MO</option> <option value="MT">MT</option> <option value="NE">NE</option> <option value="NV">NV</option> <option value="NH">NH</option> <option value="NJ">NJ</option> <option value="NM">NM</option> <option value="NY">NY</option> <option value="NC">NC</option> <option value="ND">ND</option> <option value="OH">OH</option> <option value="OK">OK</option> <option value="OR">OR</option> <option value="PA">PA</option> <option value="RI">RI</option> <option value="SC">SC</option> <option value="SD">SD</option> <option value="TN">TN</option> <option value="TX">TX</option> <option value="UT">UT</option> <option value="VT">VT</option> <option value="VA">VA</option> <option value="WA">WA</option> <option value="WV">WV</option> <option value="WI">WI</option> <option value="WY">WY</option></select></td></tr><tr><td style="text-align: left">*Zip Code</td><td><input id="required_zip" size="10" name="zip code" type="text" /></td></tr><tr><td style="text-align: left">*Email</td><td><input id="required_Email" maxlength="120" size="40" name="Email" type="text" /></td></tr><tr><td style="text-align: left">Phone</td><td><input id="Phone" maxlength="120" size="40" name="Phone" type="text" /></td></tr><tr><td colspan="2" align="left"><input type="checkbox" name="You're The Cure" value="Yes" />YES, I want to become an American Heart Association <em>You're the Cure</em> advocate.</td></tr><tr><td style="text-align: left">*Share Your Story</td><td><textarea id="required_share_your_story" rows="10" cols="55" input="" name="share_your_story"></textarea></td></tr><tr><td style="text-align: left">Upload a file:</td><td><input id="fileTest" type="file" name="fileTest" /></td></tr><tr><td colspan="2" style="text-align: left">If you're submitting a photo in support of Shared Use Agreements, please include the name and city of the pictured school:</td></tr><tr><td colspan="2"><textarea id="photo_descrip" rows="5" cols="55" input="" name="photo_descrip"></textarea></td></tr><tr><td colspan="2">By submitting your story and image you agree to hereby authorize the release of information, artwork, prose, videotape and/or photographs, concerning or related to your participation, or that of your immediate family, in American Heart Association programs and activities. You also hereby agree to hold the American Heart Association, volunteers and staff free from any and all liabilities or effects that might arise from the broadcast or publication of such information.</td></tr></tbody><tbody></tbody><tbody></tbody></table></td></tr></tbody></table><div id="divFormError">&nbsp;</div><input type="hidden" name="recipient" value="GSA.Advocacy@heart.org" /><input type="hidden" name="subject" value="Tell Us Your Story" /><input type="hidden" name="customThankYouHeader" value="Thank you for your submission" /><input type="hidden" name="customThankYouMsg" /> <div id="divcaptcha"><input type="submit" name="Submit" value="Submit" /></div></form><p>&nbsp;</p>