Submit a Photo

The Lung Cancer Alliance welcomes your pictures as we present to the world the true faces of the disease. We hope to dispel many of the misperceptions and the long held stigmas associated with lung cancer.

All fields marked with an asterisk (*) are required. E-mail addresses and phone numbers are used for internal purposes only.

*First Name:
Last name:
*Age in picture:
If deceased, check this box:	Deceased
Age at diagnosis:
Gender:	Male Female
*State:	-Please Select- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
if "other," please indicate:
Occupation:
Diagnosis:	Unknown NSCLC NSCLC-Adenocarcinoma NSCLC-Squamous Cell Carcinoma NSCLC-Large Cell Carcinoma NSCLC-Carcinoid NSCLC-Pancoast Tumors NSCLC-BAC SCLC Mesothelioma Multiple-NSCLC and SCLC
Staging of Disease:	Unknown Ia Ib IIa IIb IIIa IIIb IV Limited Extensive
Caption for Photo:
Upload photo:
	Note: MAXIMUM file size is 8MB.
*Submitter's full name:
*Submitter's e-mail address:
*Submitter's phone number:
Terms and Conditions:	Lung Cancer Alliance is the only national non-profit dedicated solely to advocating for people living with lung cancer or at risk for the disease. As part of our efforts to eradicate lung cancer we are collecting photographs of lung cancer patients as part of a campaign known as – The Faces of Cancer. If you wish to be a part of this campaign, you may submit your photograph or a photograph of your minor child who is a lung cancer patient. Please understand that your submission of the photograph(s) is your affidavit that you have the full right, power and authority to submit the photograph(s) to us and consent to the use of the photograph(s) as described below. In addition, your submission of the photograph(s) is your agreement to indemnify, save and hold us and our officers, directors, employees, and agents harmless from and against all claims, demands, actions, proceedings, liabilities costs and expenses including attorneys’ fees which may be asserted against or incurred by us and our officers, directors, employees, and agents arising out of or connected with the use of the photograph(s) as described below. Also, your submission of the photograph(s) is a voluntary disclosure of your lung cancer diagnosis or the lung cancer diagnosis of your minor child, as the case may be, and, accordingly, you hereby waive all of your rights concerning the disclosure of Protected Health Information and, if applicable, all of the rights of your minor child concerning the disclosure of Protected Health Information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our use of the photograph(s) includes our duplication, alteration, revision, enhancement and all other modifications we may make to the photograph(s) as part of The Faces of Lung Cancer campaign and such other marketing and public relation campaigns and uses similar to our The Faces of Lung Cancer campaign. Further our use of the photograph(s) includes our use of the photograph(s) in all media (including the web and print media) in connection with The Faces of Lung Cancer campaign and such other marketing and public relation campaigns and uses similar to our The Faces of Lung Cancer campaign in which we may engage in from time to time. Lastly, photograph(s) received by us become our property and we will NOT return any photograph to you.
	By clicking submit below, you are indicating that you agree to the terms and conditions stated above.