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Vaccine Injury Video Upload

Steps 1 and 2

Submit your memorial video in 3 easy steps! Steps 1 and 2 are located below and once you've completed the information below you will be directed to a confirmation page where you will be able to upload your video. All fields below are required to be completed so that we may contact you, if we have any questions about your submission.

Optional - Any VICP documentation you choose to submit with your video will not be published, and is used solely for verification purposes.

Step 1 of 3: Tell Us About Yourself

Contact Information for Person Posting Video Vaccine Reaction Report:

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Your Story

Step 2 of 3: Agreement

To submit your video, please check the box below stating you have read and accepted the submission agreement.

By submitting my video, I acknowledge I have read and agree to the video submission agreement.

Video submission agreement: I represent and warrant that I am at least 18 years of age and I have all authority necessary to agree to and grant the permissions given in this Agreement. I understand that by submitting my video, testimonials, stories, quotes and/or other information through this website (the “Submission”), I grant the National Vaccine Information Center (“NVIC”) a perpetual license to use, distribute, edit or republish my Submission, in whole or in part, including without limitation my name, likeness, and voice, for advertising, promotion, and any other purpose desired by NVIC, in all or any media now known or developed in the future, including the Internet, and anywhere throughout the world, without limitation as to duration or frequency of usage, and with or without attribution to me, at NVIC’s sole discretion, with the exception of federal vaccine injury compensation program (VICP) documents submitted. VICP documentation that is optionally submitted to NVIC will be not be republished, and used only to verify statements relating to VICP award or denial statements made in the Submission.

I acknowledge that NVIC is under no obligation to use my Submission and may decide, at its sole discretion, not to use the Submission. I waive any inspection and/or approval of the use of the Submission and hereby release NVIC, its agents and assigns, from any obligation to make payment hereunder and from any liability incurred in connection with the use of the Submission. I agree to hold NVIC, its agents and assigns, who use the Submission harmless against any claims, losses, damages or liability arising from such use.

I represent and warrant that any statements made by me in the Submission are true, accurately reflect my vaccine reaction experience. The Submission is my own work and I have all necessary consents from any third parties that are included in or referenced to in the Submission. Upon request, I will promptly provide written support for (i) any claims made in the Submission that are or appear to be factual, and (ii) any necessary third party consents.

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