Tell us your story

If your life has been affected by cancer, and you would like to be featured in our Portraits gallery, please fill out the form below.

Contact Information

Name

City

State

Your Story

Cancer Type or Role

Your Story

Upload an Image

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Do you have a video that you would like us to use? If you would like to include a video with your portrait, someone will be in touch.

I, the undersigned, do hereby consent to the use by the Illini 4000 for Cancer and the Portraits Project of my image, voice, or both, reproduced either in whole or in part, for purposes including (but not limited to) fundraising, advertising, publicity, Web or print publication, informational display, or any other activities on behalf of the Illini 4000 for Cancer and the Portraits Project. I warrant that I am at least 18 years of age, or that my legal guardian has agreed to the preceding statement and will co-sign this consent form.