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Thank you in advance for sharing your account of a vaccine-preventable disease with the Immunization Action Coalition (IAC) via this online form. Please note: Submission of your story does not guarantee its publication on IAC's websites and/or publications. If your personal testimony is selected for publication, IAC will contact you by phone or email for your final approval.
FIELDS MARKED WITH * ARE REQUIRED
 
* First Name:
     
* Last Name:
     
* Address:
     
* City:
     
* State or Province:
     
* Zip Code:
     
Phone:
     
* Email Address:
     
* Confirm Email Address:
     
* Disease:
     
Comments:
     
* Submit Story:
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* Permission
By checking this box you give IAC permission to publish your story
     
   
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Questions/problems? Contact us at testimonies@vaccineinformation.org