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2. Share Your Story

   If you would like to share your story to help raise awareness of child and teen drowning with the DuPage County Health Department, please fill out  and submit the form below. Please mark your story as, 'public' or 'private' as portion of 'public' stories will be selected for an upcoming awareness campaign. Your story will not be shared without your permission. We sincerely appreciate your willingness to contribute your story.

    

4. First Name *
6. Last Name*
8. Email*
10. Phone Number*
12. Personal Story*
14. Authors County and State of Residence
16. Permissions*

    1. Public
    2. Private
Leave This Blank:


18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit

* indicates a required field