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Spinal Champion® Story Form

Patients facing a debilitating back or neck condition can often feel lost, alone, and overwhelmed – but the road to recovery doesn’t have to be a lonely one. Our Spinal Champion program brings together individuals who have achieved improved quality of life through treatment for their neck or back pain to share their own stories of hope and provide encouragement to other patients. Spinal Champions help others find strength, comfort, and peer-to-peer support in a community that understands. We would like to share your story to help give hope to others. In your own words, please answer the following questions. Once your story is reviewed and accepted, we will send you a Spinal Champion lapel pin to the address that you provided.
First and Last Name*
Street Address*
City, State Zip*
Email*
I consent to possibly having my First Name, Last Initial, and Photo be shared along with my story on our social media platforms.*
Yes
No
We would also love to put a face with a name! Please include a headshot and/or action shot of yourself to include with your bio.
Accepted file types: jpg, png, Max. file size: 50 MB.
Please provide a 150-300 word bio that covers your journey back to spine health. Please include: A general timeline of events (month/year)

Diagnosis (if more than one, please list all)

When symptoms began and any precipitating events (e.g. an injury or accident)

When you sought treatment

The type(s) of treatment(s) you received

If you had surgery, what type of surgery and when was it

Description of the recovery process (including any physical therapy or additional treatments needed)

When you were able to resume your normal activities

A little bit about yourself

Occupation

Age when symptoms began

Activities you continue to enjoy
Bio
I would like to have my story considered for the 'Get Back To It' Podcast*
You can listen to our podcast here
Yes
No
I am interested in being considered for a “Spinal Champion Advocate” volunteer role in which I will have the opportunity to speak to other patients about my experience as a Spinal Champion*
You can learn more about our Spinal Champion Advocates here
Yes
No
Physician/ Provider’s First & Last Name
Practice’s Name
Location (City, State)
CAPTCHA
Signature*
I, (First & Last Name)
hereby irrevocably authorize the National Spine Health Foundation, its agents and assigns the unrestricted right to produce and use in any format (including the use of any electronic or similar media) including without limitation my voice, my person, likeness and/or medical devices that are used by me internally or externally (all such media representations sometimes referred to as my “likeness”). On behalf of myself, my personal representative and assigns, I transfer, and release any and all claims of ownership of the media representations of my likeness so produced to the National Spine Health Foundation to be used by them and their assigns for their exclusive use without any further consideration, or my prior approval. All such representations of my likeness may appear in any publications of the National Spine Health Foundation (electronic or print), including without limitation, the National Spine Health Foundation website, brochures, advertisements, and/or publications. I understand that all or a portion of any such likenesses may involve the disclosure and use of individually identifiable health information or other medical records; accordingly, this release is to be applicable to all information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you have any questions or concerns, please email patientresources@spinehealth.org
Name
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