Spinal Champions® Form

Spine-Talks® Spinal Champions® present stories of healing and recovery from Spinal Champions® , those who have experienced an improved quality of life through neck or back treatment. View our full Spine-Talks® library here.

Spinal Champion®

  • A Spinal Champion® is a person who has achieved an improved quality of life through treatment for neck or back pain! We know the journey to spinal health is not one that can be made alone and encourage Spinal Champions® to share their story, giving hope to others battling similar challenges. It is inspiring and rewarding to see these individuals getting back to the activities and people they love, which is why we would like to hear from you, as a Spinal Champion®.

    National Spine Health Foundation improves spinal health care through education, research, and patient advocacy. We would like to share your story to help give hope to others. In your own words, please answer the following questions:

  • Max. file size: 2 GB.
  • 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 efredericks@spinehealth.org

Hear from other Spinal Champions® on our Get Back To It Podcast, stories of hope and recovery and join our Facebook Support Group.

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