Share your story!
We love hearing from our patients. If we’ve had an impact on you or someone you know, share your story with us today so that it can help inspire others.
Want to reach us by phone?
We’re available Monday through Friday at (855) 845-3663, 8 a.m. – 7 p.m. ET, excluding holidays.
Need our address?
The Assistance Fund is headquartered at:
The Assistance Fund
8427 Southpark Circle, Suite 100
Orlando, FL 32819
Testimonial Release Form
I hereby give my full permission for The Assistance Fund, Inc. to use my likeness in photograph, video, and/or audio recording, including any written statements I may make and The Assistance Fund, Inc. may use the same in print, video, digital presentations, on The Assistance Fund, Inc. website, on The Assistance Fund, Inc. affiliated websites, and in any other similar and reasonable manner. The Assistance Fund, Inc. is authorized to produce and distribute media in any form that contains my photograph, video, written statements, and/or audio recordings as part of The Assistance Fund’s testimonials. This consent includes the use of materials with or without my name and biographical data concerning me.
I, generally, fully and forever release, indemnify and discharge The Assistance Fund, Inc., its officers, directors, employees and affiliates from any and all causes of action, claims, demands, liabilities and obligations of any kind, whether known or unknown, arising out of or relating to the disclosure or use of my likeness in photograph, video, and/or audio recording, including any written statements I may make, including any claims for compensation related to The Assistance Fund, Inc.’s testimonials. I expect no compensation or other remuneration for the use or disclosures that are part of The Assistance Fund, Inc.’s testimonials.
I understand that I may revoke this authorization at any time by notifying The Assistance Fund, Inc. in writing, except to the extent that action has been taken in reliance on this authorization. [Unless I revoke this authorization, it will expire ten years of date set forth below.
I have read and understand the terms of this Authorization and Release and I wish to voluntarily participate in The Assistance Fund, Inc.’s testimonials.