Your details

 
Name(*)

Telephone(*)

Email Address(*)

Zip code(*)

Preferred contact method(*)
EmailPhoneTextphone
 

Details of stroke survivor (if applicable)

 
Name

Date Of Birth

Physical impact of stroke (loss of voice or use of limbs etc) Please no more than 200 words

 

Stroke victory

For each question, please provide no more than 150 words

What was your challenge?

How long did it take you? (years, months, days)

Why did you want to achieve this goal?

What motivated you to keep going?

How did you feel when you achieved your goal?

What advice, tips or information would you like to share with others?

 

Tips for submitting videos or photographs

A picture can tell a thousand words. Action shots will capture readers’ interest and inspire them to read your story much more than a head shot. Try and capture the person "doing" an activity. Don't be afraid to use humor in your photos. Videos should be high quality and no more than 2 minutes long. We will use your photo with your story. So please think about a caption and ensure you have the permission of everyone in the photo so that we can use it on our website. Make sure your photos are clear and in focus. All images need to be high resolution, the bigger the better. Please send in jpg or tif format. Please send your photo to: Email: support@pacificstrokeassociation.org Please do not forget to provide a caption for your photo and everyone’s name in the picture.

Consent

I give my permission to Pacific Stroke Association to post my story and any photographs I have supplied on the Pacific Stroke Association materials and on the Pacific Stroke Association website. I understand that I will not receive any payment or royalties for this. Pacific Stroke Association reserves the right to use or not use any stories submitted.*

Please click if you have understood and give permission(*)

Name(*)