Share Your Story - Stand Up*Speak Up (SUSU)

If you are comfortable, and safe sharing your story "knowing it will be posted online" we'd love to hear from you!! We want to get to know you, connect with you, and support you. We are excited to feature you on our platform!

Today's Date *

Date

Full Name *

First Name Last Name

E-mail *

Phone Number *

Area Code Phone Number

Your Social Media

Please attach a photo that makes you feel strong, and confident

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Are you safe?

Yes! No! If no, we ask that you reach out to us for support, and consider sharing your story once you are safe.

Are you comfortable with us making your story public? *

Yes! No!

Your story goes here *

If the box above is doesn't allow enough space to type please upload a Google document here.

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Based on your experience what do you have advice for others? *

May we contact you to talk more about this experience? *

Yes, please. No, thank you.

Are you interested in being contacted to share your testimonial via video or audio recording? *

Yes, please. No, thank you.

I authorize you to use this testimonial information in marketing materials. *

Yes! No!

I wish to remain anonymous. *

Yes! No!

CONSENT:

Survivor Story Photograph and Publicity Release Form.

I acknowledge that by submitting my survivor story to Women Helping Encouraging Women aka WHEW, Inc., I am granting WHEW, Inc. permission to use and publish my story online without regard to where it was previously published or quoted, such as news articles, personal social media, and blog accounts, blog sites run by a third party curator, etc. I agree that WHEW, Inc. has complete ownership of this story, including the entire copyright, and may use the story for any purpose consistent with WHEW, Inc’s mission. I also give WHEW, Inc. permission to use my name*, likeness, image, voice, story, and/or appearance as such in any pictures, photos, video recordings, audiotapes, digital images, publications, and the like, taken or made on behalf of WHEW, Inc. UNLESS I check the box “I WISH TO REMAIN ANONYMOUS,” on the website, in which case WHEW, Inc. only has permission to use and publish my story. *Only first names are used in publishing survivor stories unless otherwise dictated by the survivor.

I have read and understood this consent and release form. *

Yes

Signature

Clear

Please verify that you are human *

Stand Up * Speak Up