If you are a breast cancer survivor or know someone else who is, The Balancing Act would like to hear from you.

We’re looking to raise awareness for breast cancer, and offer inspiration by highlighting some of the heroes who fought and won their cancer battle.

Survivor stories may be submitted by either a video (no longer than 30 seconds please), or with a photo and a brief written story. In the case of a video submission, please first upload it YouTube, and then provide us the link to the YouTube video. We’ll be featuring some of the stories throughout the month of October in conjunction with Breast Cancer Awareness Month.

Story Submission
	First Name
	Last Name
Email:
Phone:
Address:
City:
State:	Select One NOT IN US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Zip:
Birth Date:	Year 19201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008    Month 123456789101112    Day 12345678910111213141516171819202122232425262728293031
	Photo (less than 1mb in size)
	Tell us your story.
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	YouTube video link (URL to a Youtube page with a video of you.)
Video Link characters left
	I agree that The Balancing Act may share my story on the show.
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