Form Center

By signing in or creating an account, some fields will auto-populate with your information.

Protect Swimmers 10M: Share Your Story

  1. 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.


  2. Permissions*
  3. Leave This Blank:

  4. This field is not part of the form submission.