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Your Story Submission Form

If you have a personal story or poem that you would like to see published on our site, then please send it to us via this form.

Note: by submitting a story you are asserting that you hold the rights to the submitted material and are granting the Alzheimer Society the right to publish it on this web site and to attribute it to you.

Your email address will not be disclosed, but we may need to contact you before we can publish your story.

We can not publish all of the stories or poems that are submitted, so please be aware that there is no guarantee that yours will be published.

Feel free to email us your photo too. We may also wish to include your story in our other published materials. If this is the case, we will contact you separately so please ensure your email address is correct.

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What is your name? (required)

What is your Email address? (required)

Please enter the title of your story or poem: (required)

Please enter your story or poem into this box: (required)