Birth Story and Photo Release Form
I hereby declare that I am granting permission of use to Special Scars ~ Special Hope, Inc. (the Organization) my child's birth story and/or one or more still photographs of myself and/or my family and myself.
My Name *
Your answer
My Email (a Special Scars web editor will be in touch regarding collection of your story and any photos you wish to share). *
Your answer
The child's name and date of birth are: *
Your answer
Type of Scar *
Your answer
The Organization is hereby authorized to use or cause to be used said story, still photographs and my name for advertising, publicity, the news media commercial or other business purposes. Said photographs may be used singularly or in conjunction with other photographs.

The Organization has my authorization to reproduce, or cause to be reproduced and used such stories and photographs both in print and electronically over the Internet. The same may be exhibited in all domestic and foreign markets. I understand that others may use and/or reproduce said stories and photographs, including the new media, with or without the Organization's consent.

I hereby release the Organization, any of its associated or affiliated organizations, their directors, officers, agents, employees, customers and the Organization's appointed advertising agencies, officers, directors, agents and employees, from all claims of any kind on account of such use.
By typing my name in the box below, I am granting the above listed permissions and releases. *
Typing my name in this box constitutes a legal signature.
Your answer
Please print before clicking on the Submit button if you want a copy for your files. Thank you!!
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.