Share Your Story
Story collection is a powerful communications and organizing tactic demonstrating the urgent necessity of access to reproductive, sexual, and preventive health care. Storytellers enable others to understand who they are and why it’s important to take action to protect our rights and access. Facts can only get you so far, we need people to empathize with these issues and how they impact real life people. We, at Planned Parenthood, are privileged to hear amazing stories from our patient advocates and supporters all the time. Now, we are asking you to share your story! Please consider sharing with us.
First Name *
(Your story can be published anonymously, but we need your name for consent and usage)
Your answer
Last Name *
Your answer
How would you like your name listed with your story? *
Phone number *
Your answer
Email *
Your answer
Address 1 *
Your answer
Address 2
Your answer
City *
Your answer
State *
Your answer
Zip Code / Postal Code *
Your answer
Are you 18 years of age or older? *
If you are under 18 you must have parental consent to share your story. Please email volunteer@ppmi.org for instructions on how to get parental consent and submit your story.
Please write your story here: *
Your answer
Consent to publish story *
For good and valuable consideration, receipt of which I hereby acknowledge, I specifically grant to Planned Parenthood Action Fund, Inc. and Planned Parenthood Federation of America, Inc. (“Planned Parenthood ”) and their affiliates, successors and assigns, and to such other persons as Planned Parenthood may designate from time to time (“Licensees”), the absolute and irrevocable right to take, use, publish, reproduce, and distribute my story as written on this form, with the limitations, if any, described on this form, in the United States or elsewhere in the world at any time in perpetuity.I agree that any pictures or images taken of me or sound recorded of me by the Licensees are owned by them, including any reproductions, derivatives or alterations thereof. If I should receive any photograph, image or recording from Planned Parenthood, I shall not authorize its use by anyone else.Without limiting any of the foregoing, I (1) irrevocably consent to and authorize the reproduction, alteration and publication of my story, images or recordings, in whole or in part or in conjunction with other photographs, images, audio recordings and/or text, or in any altered or derivative forms, without any further compensation to me and (2) specifically waive any right to inspect or approve the final photography, images or recordings (or any derivatives or alterations thereof) that may be taken, used, published, reproduced, distributed or copyrighted hereunder.I specifically release Licensees and all personnel associated with Licensees of any and all liability to me and/or my property of any and every nature, including but not limited to any and all claims of defamation, privacy or publicity, arising out of the use or uses of my name, voice, likeness, photography, image or recording as contemplated herein. I further agree that I will not hold Licensees, or anyone who receives permission from Licensees, responsible for any liability resulting from the use of my name, story, voice, portrait, likeness, photograph(s), image(s) and/or recording(s) in accordance with the terms hereof, including what might be deemed to be misrepresentation of me, my character or my person due to distortion, optical illusion or faulty reproduction which may occur in the finished product.I warrant and represent that this license does not in any way conflict with any existing commitment on my part.
Required
Signature (Please type your full name) *
Your answer
Date *
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