Testimonial Submission Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Share Your Registry Story Your experience can help others understand what the FTD Disorders Registry is, why participation matters, and how joining the Registry can support the future of FTD research. We invite Registry participants, family members, care partners, researchers, healthcare professionals, and supporters to submit a short video testimonial. Your video may be shared on the Registry website, social media channels, in newsletters, presentations, or other educational and promotional materials. Videos do not need to be professionally produced. A sincere message recorded on your phone is perfect. What You Might Talk About You could share: Why you joined or support the Registry Why FTD research is important to you What participating in the Registry means to you or your family Your experience connecting with a research opportunity through the Registry Why you would encourage someone else to join How you hope the Registry will help advance FTD research Aim for a video that is approximately 30 seconds to two minutes long. Please record in a quiet, well-lit location and speak directly to the camera. Submit Your Video Your Information Full Name *Email *We will use your email only to contact you about your submission. It will not be published with your video. What is your connection to the FTD community? *Person diagnosed with FTDCurrent care partnerFormer care partnerFamily memberPerson with a known or potential genetic link to FTDFriend or supporterHealthcare professionalResearcherRegistry partner or community organizationOtherWhat is your other connection to the FTD community? *About Your Video How would you like your name to appear if your video is shared? *My full nameMy first name onlyPlease do not display my namePlease provide a short description of your video. *For example: “I joined the Registry after my mother was diagnosed with FTD because I wanted our family’s experience to contribute to research.”Submit Your Video * Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera Camera Preview Please do not include anyone else in your video unless they have also completed a release form.Video Testimonial Release By submitting this form, I give the FTD Disorders Registry and its authorized representatives permission to use, reproduce, edit, publish, display, distribute, and share the video, audio, image, name, and statements I submit through this form. I understand that my submission may be used in Registry communications, including but not limited to websites, social media, email newsletters, presentations, educational materials, promotional campaigns, conference materials, and media outreach. I understand that: My video may be edited for length, clarity, formatting, accessibility, or presentation. My submission may be used in whole or in part. I will not receive payment or other compensation for the use of my submission. My participation is voluntary. I may contact the Registry to request that my video not be used in future materials. I understand that the Registry may not be able to remove materials that have already been published, distributed, printed, or shared by others. The Registry is not required to use my submission. I should not share private medical information or information about another person unless I have permission to do so. Release Agreement *I have read and agree to the Video Testimonial Release above. I confirm that I am at least 18 years old and have the authority to grant this permission.Electronic Signature * Clear Signature Submit
