Collection Form

Lupus has many voices. Add Your Voice »

Add My Voice (Public Profile)

State (Required)

Public Profile Name (Required)

I am (Required)
Living with Lupus
A Lupus Supporter

What do you want others to know about lupus? (Required. Maximum 365 characters.)

How has lupus impacted your life? (Maximum 1340 characters.)

Personal website or blog

YouTube Video

Want to include a video with your Lupus Voice profile? Find your video on YouTube, click share, and copy/paste the URL (must be in the format of http://youtu.be/H8LwE-oNi4o)

Profile Image

If you do not upload a photo, the purple butterfly image will appear on your profile

Contact Information for the LFA

First Name (Required)

Last Name

Email (Required)

Lupus Voices Password (Required)

Verify Password (Required)

Passwords must be at least 7 characters

Zip Code

City

Please send me periodic updates about events, programs and activities from the Lupus Foundation of America and the LFA Chapter which serves my area.

Author's Release

I certify that I am at least 18 years old. I am submitting information for myself or I am the legal guardian submitting information on behalf of my child. I grant permission to the Lupus Foundation of America, Inc. (LFA), their successors, assigns, and those acting on their authority to publish or share the story I am submitting. I further warrant that the story herewith was prepared by myself (or someone directed by me) and is true and accurate. I understand that, if selected for use, this story may be copy edited to ensure ease of comprehension and adherence to the rules of English grammar. 
        
In addition, the LFA editorial staff may also substitute different words and/or revise sentence structure for clarification. I further understand that this material may possibly be re-titled and/or reprinted in other LFA publications or shared with the news media and made public. 
        
I acknowledge that I have not included any information in my submission that I wish to keep private. I possess full legal capacity to exercise this authorization and  hereby release Lupus Foundation of America, Inc. and its officers, employees and agents from any blame by myself, my successors, and/or my assigns. This authorization shall remain in force until canceled by me, but I recognize that withdrawal of authorization cannot be made retroactive to those who have received my information prior to my notification. 
        
I understand that to cancel authorization for future releases of my story, I must send an email to voices@lupus.org with my name and address and any additional information that may be helpful to identify my profile and story in the database.

I have read the authors release and accept the terms

Please send us an email to request that your profile be deleted.