1,000 Voices | Share Your Voice

1,000 Voices | Share Your Voice
Name*

First NameLast Name
Email*
example@example.com
What is your Organization and Title? or How do you identify?
What is your relationship to South Pinellas County? (Select all that apply.)

I live hereI work hereI own a business hereI go to school hereI practice my faith hereOther
When you envision an equitable St. Petersburg, what change(s) would you like to see? *

0/200
How does race impact your life?

0/200
Home Zipcode
Answering this question helps improve outreach for representation across Pinellas county, but is not necessary.
Image *Required*

Please choose to schedule a photography session with our photographer within St. Petesburg, FL OR upload a high resolution photo to be included with your quote, below. Accepted file types include .jpg, .png. Please note FHSP staff will reach back out if we require a larger photo size or type.
I'd like to schedule a session with the Foundation's photographer.

YesNo, I'll submit my own image below.
Add a video of you sharing how race impacts your life (optional)

Browse Files

Cancelof
Who else should we be listening to? We'll reach out to them to see if they'd like to share their voice and be featured in 1,000 Voices.

First NameLast Name
What is their email address?
example@example.com
PHOTO AND VIDEO RELEASE

I grant permission to use my photograph or video recording of me in print or online materials designed for news, informational, educational or advocacy purposes by UNITE Pinellas, the Foundation for a Healthy St. Petersburg or the Center for Health Equity.

I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, Internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product.

I hereby release, acquit and forever discharge the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.

I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.
Signature *Required*

Clear
If individual photographed/recorded is under eighteen (18) years old, the following section must be completed: I have read and I understand this document. I understand and agree that it is binding on me, my child (named above), our heirs, assigns and personal representatives. I acknowledge that I am eighteen (18) years old or more and that I am the parent or guardian of the child named above.
Name of Parent/Guardian of the Individual Photographed/Recorded

First NameLast Name
Signature

Clear
Should be Empty:

1,000 Voices | Share Your Voice

Image *Required*

Image Required