Share Your Story

I am a:                       SELECT BELOWPatientCaregiverFamily MemberFriend of A PatientWidow / WidowerOther
First Name:                
Last Name:                
Address:                    
City:                           
State:                         SELECT BELOWAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Zip / Postal Code:      
Country:                     
Phone:                       
Email:                         

POSTED VICTIM’S STORY INFORMATION (For a person exposed, patient diagnosed with
asbestos- related disease or descendent)

Name:                          
Date of Birth:               
Date of Diagnosis:       
Diagnosis:                   —Please choose an option—AsbestosisPleural Plaques/ScarringMesotheliomaLung Cancer With Documented Asbestos ExposureOther Cancers With Documented Asbestos Exposure
Treatment (optional):   

Date of Death:             
(if applicable)

Photo:
Submitting a photo is a requirement in order for ADAO to consider your story for a dedication and/or in other communication or promotional materials.

(Photo size must be less than 100MB–otherwise, you will see an error screen instead of posting your material. Also, please do not put spaces in the filename, and only .jpg, .jpeg, png and .gif images are allowed.)

How has asbestos changed your life?
(300 word count maximum):



By submitting my story, I agree that ADAO may use
my story and photo in educational and advocacy materials.

ADAO will not sell, trade, or rent your personally identifiable information to third parties.
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