Use your voice to inspire others

You have a unique story, and we want to hear it!

When you share your experiences, you give hope to others in the PAN community and help us raise awareness about the healthcare affordability crisis.

Annual report 2020: storytelling form

Used in 2021 for 2020 annual report storytelling

Step 1 of 2

Full name*
Email*
Birthdate*
MM slash DD slash YYYY
State*
Disease fund (s)*
Insurance type*
Tell us a little bit about yourself, including something that makes you smile.
How has your PAN grant impacted your life? (If you have multiple grants, please describe both.)*

What would you like people to know about what it’s like to live with a serious condition?**
If you could give one message to lawmakers about out-of-pocket medication costs, what would it be?*
What else would you like to share about your experience?
If you would like to include photos or videos with your story, please upload them in the box below.
Drop files here or

Accepted file types: jpg, gif, png, jpeg, mp4, mov, Max. file size: 50 MB, Max. files: 6.
Size limit for each file is 50 MB; maximum of 6 files.
Please consent to our Terms and Conditions

Please read this carefully before you share your story and any personal information or media, and any other content, including your image, with us. By submitting information to the PAN Foundation and clicking “I agree,” you’re confirming that you have read, understand, and agree to the PAN Foundation’s Terms and Conditions as follows:
- You understand and agree that we may use your content for any informational, fundraising, or promotional or other purposes.
- You understand and agree that we can use and display any of your content and personal information that you provide in any format.
- You give us the right to verify the information you submit with other information we may have in our files.
- You give us the right to contact you for additional information if we think it would be helpful or necessary to do so.
- You understand and agree that you will not be paid or reimbursed in any way for your content or other information you provide to us.
- You consent to the use, distribution, and redistribution of your content and information by the PAN Foundation and its employees, contractors, and representatives.
- You understand and agree that you do not have the right to inspect or approve any finished product.
- You release and agree to indemnify and hold harmless the PAN Foundation, its employees, contractors, and representatives from any claims, lawsuits, injury and/or damages as a result of the content and information you provide to us.
This includes but is not limited to claims for personal injury (including injury to reputation), property damage, invasion of privacy and/or breach of confidentiality.
Download our Terms and Conditions (PDF 230KB)
Consent*
I agree with your terms and conditions*
I am interested in future opportunities to share my story with the PAN community
Email
This field is for validation purposes and should be left unchanged.

Use your voice to inspire others

You have a unique story, and we want to hear it!

Annual report 2020: storytelling form

Step 1 of 2

Please consent to our Terms and Conditions