Request A Story

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First Name *

Last Name *

Credentials

Affiliation *

Name of your organization/agency *

Address *

Email *

Are you a student? *

Name of your school

How did you hear about Shot By Shot? *

For what purpose would you like to use SBS stories? *

Please explain: *

Who is your expected audience? *

Please describe event, meeting, or project here *

What date(s) will you plan to show the SBS video?
(Note: We'd like to check back with you to find out how many people you estimate might have seen the videos during the time.)

Start Date *

End Date *

When you share the stories will you have any opportunity for audience feedback? *

Yes
No

Consider distributing this 2-question survey to the people in your audience and share aggregate results with us.

We will be in touch with you after your event is over.

Please confirm your agreement to the following: *

I/WE will use SBS Stories only in accordance with the California Immunization Coalition’s mission.
I/WE will not edit or alter any SBS Story.
I/WE will not sell or make a profit from using any SBS Story.
I/WE will not transfer copies of any SBS Story to any individual or entity without the express, written permission of the CIC.
I/WE will use SBS Stories only for educational or information purposes (e.g., in a classroom, community program, training, outreach event, professional conference, media report, or personal or family use).
I/WE understand and agree that any permission I/WE receive from SBS may be revoked by SBS, without cause, upon notice sent to me via the email address provided below. Immediately upon SBS's dispatch of such a revocation notice, I/WE will stop all uses of any SBS Stories, including without limitation, removing them from websites.
I am authorized to enter into this agreement on behalf of the below listed organization (if any), and both I and said organization will be bound by this agreement.
I/We understand and agree that CIC and SBS do not vouch for or guarantee the accuracy of the information or statements made in the SBS Story, nor that they may be used without violating copyright, trade secret, privacy and other laws (or rights of third parties). I/We assume all risk for any use we make of said SBS Story (Stories), and waive all claims, damages and causes of action that I/We may come to have against CIC and/or SBS, including without limitation, claims for indemnity. I/We understand that it is our responsibility to verify that such stories may be used without violating applicable laws or rights of third parties.
I/We agree that, no lawsuit may be filed or heard relating to this agreement, concerning the subject matter thereof, or seeking to enforce the terms thereof, except before the State and Federal Courts located in Sacramento, California, and I/We hereby submit to the personal jurisdiction of such Courts.
I/WE understand that by checking this box and submitting this form electronically, a binding legal contract is being formed.

I agree to: *
complete and return a brief survey to help measure the impact of my use/my organization's use of Shot By Shot stories.

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who we are

Stories put a face on vaccine-preventable diseases. Our collection of videos and written stories is an education and awareness resource for your patients, colleagues, students, clients, and community.

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