Share Your Story

Introduction goes here.

Name*
First Last
Email*
Phone*
This is for our use to contact you, if necessary. It will not be made public.
Have you filed a case in VICA (Vaccine Injury Compensation Act)?*
- Yes
- No
- I don't know
What is birth year of affected child?*
Location*
City State / Province / Region ZIP / Postal Code Country
Your Story
Agreement*
- I agree
I understand that my story and that of my child may be shared at childrenshealthdefense.org and on social media platforms. I also understand that my story may be edited for brevity.