Share Your Story
Breakaway from Cancer® Inspirational Stories Submission Form
Breakaway from Cancer seeks to share the inspirational stories of cancer survivors across the country. If you complete the form below, your story may be posted on this website. A Breakaway from Cancer representative may contact you for additional details or information.
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Amgen is interested in engaging patients, their caregivers, and/or family members who would like to share their experiences with cancer through Breakaway from Cancer®, a national initiative to increase awareness of important resources available to people affected by cancer -- from prevention through survivorship.
If you are under the age of 18, you are not eligible to participate, and we ask you not to submit any personal information to Amgen.
For the purpose of advertising and/or promoting the Breakaway from Cancer® initiative, I authorize Amgen and its contractors that service Breakaway from Cancer® to use and/or disclose the health information I supply (“Health Information”). Amgen and its contractors will not disclose the Health Information for any other purpose, except as required by law. I understand that once the Health Information has been shared with Amgen, federal privacy laws may no longer protect it from further disclosure.
My authorization will expire in 10 years, or less if required by state law, unless I cancel it sooner. I may cancel this authorization at any time and for any reason. To cancel this authorization, I agree to notify Amgen via email@example.com. Once Amgen receives and processes my cancellation email, Amgen will not use the Health Information going forward. I understand that cancelling my authorization will not affect any use or disclosure of the Health Information by Amgen or its contractors that occurred before my request was received and processed.
I am entitled to receive a copy of my authorization. Click here to print this page.
By clicking the “I Agree” button below, I am electronically signing this Authorization to Use Health Information (which has the same legal effect as a handwritten signature) and indicating that I am at least 18 years old and authorize Amgen and its contractors to use and disclose the Health Information for the purposes described above.
If you do not wish for your Health Information to be used and disclosed with Amgen for the purposes described above, you should not sign this authorization.
Release of Publicity Rights
I hereby grant and assign to Amgen and its subsidiaries, successors, agents and assigns (collectively referred to as the “Released Parties”), my rights including, but not limited to, the use, reuse, reproduction, modification, publication, display, transmission, and performance in any and all media now or hereafter known of my name, photograph(s), statements made by me, motion pictures, videotape, audio recordings, internet postings or other web publications, or other likeness of me, alone or with other persons (“Publicity Rights”) and for the purpose of advertising and/or promoting the Breakaway from Cancer® initiative (“Publicity Rights”). Amgen promises to use the Publicity Rights only while the Authorization to Use Health Information is in effect.
On my own behalf, and on behalf of my heirs, executors, administrators, successors and assigns, I release and discharge the Released Parties from any liability by virtue of the exercise of their rights in the Publicity Rights, including without limitation any blurring, distortion, alteration, optical illusion, or use in composite form that may occur or be produced regarding the use of my name or the taking of said photograph(s), statements made by me, motion pictures, videotape, recordings, internet posting or other web publication, or other likeness of me in any processing thereof through completion of the finished product, and including without limitation any liability based on rights of publicity, invasion of privacy and other civil rights, moral rights, copyright infringement, defamation, libel and slander. I waive any right that I may have to inspect or approve any uses made of the Publicity Rights in connection with this consent/release.
I understand that I will not receive any royalty or other monetary compensation, now or in the future, for my Publicity Rights including but not limited to the use of my photograph(s), statements made by me, videotape, or other likeness or reproductions of me and recordings.
By clicking the “I Agree” button, I also am electronically signing this Release of Publicity Rights (which has the same legal effect as a handwritten signature).