Family House Story

Guest Name*

First Last

Patient Name (if different)

First Last

Length of Stay at the Family House*

Have you stayed at the Family House Before?*

Yes
No

Reason for Stay*

Pre-Transplant Appointment
Post-Transplant Appointment
Transplant Surgery
Emergency Hospitalization

Transplant Center*

Share your transplant story here. Consider including: 1. How long you have been ill, what stage of the transplant process you are in now, and what has the overall transplant process been like for you; 2. How the Family House impacted your transplant journey; 3. What was most memorable about your stay at the Family House.

In consideration of Transplant House d/b/a Gift of Life Family House (“Gift of Life Family House”) accepting my submission, the adequacy of which is hereby confirmed: I authorize Gift of Life Family House and its affiliates to copy, reproduce, modify, edit, and use the submitted information and media provided by me for any purpose (including education and marketing) and in any form (including electronic and print media) throughout the world and in perpetuity. I release Gift of Life Family House and its affiliates from all claims, liabilities, or causes of action arising out of my submission or the subsequent use of the above information and media, and from any obligation to compensate me for use of this information and media. I waive the right to review, approve any such use. I understand that Gift of Life Family House and its affiliates are not obligated to use this information or media. I authorize Gift of Life Family House (“Gift of Life Family House”) to use my first name, last initial and city when publishing my Family House Story, unless I otherwise request to remain anonymous by checking below. I acknowledge that Gift of Life Family House cannot guarantee my anonymity.*

I have read and accept these terms and conditions.

I would like to remain anonymous

Yes
No

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