Submit a Design, Song, Poem, Written Work, or Presentation

Submit a Design, Song, Poem, Written Work, or Presentation

Thank you for your support! Please read and agree to the terms and conditions before submitting your work. We greatly appreciate your support of our mission to end sexual violence and support survivors. Please note in completing this form, you understand and agree that TBTN may use your submission and data as part of its aggregate reporting, operations, and internal review. TBTN does not sell your personal data or contact information to any 3rd parties.
Full Name*

First NameLast Name
Your School, Organization or Company*
Put None if not affiliated.
Phone (US Country Code = +1; Canada Country Code = +1; Australia Country Code = +61; UK Country Code = +44; find other Country Codes at https://countrycode.org/)*

Country CodeArea CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*

Confirmation Emailexample@example.com
Birth Date

MonthDayYear
Demographics

This information is needed for our non-profit status and other metrics, including those established by grants, governmental agencies, and other NGOs.
I identify as:*

FemaleMaleTransgenderNon-binaryI prefer not to sayOther
My preferred pronouns are:*

She/herHe/himThey/themZe/zemOther
I identify as:*

Black or AfricanHispanic or LatinoWhiteAsianAmerican IndianPacific IslanderTwo or more racesUnknownI prefer not to sayOther
I identify as:*

Heterosexual/StraightGay or LesbianBisexualI prefer not to sayOther
My age is:*
Please provide a short bio of yourself (3-5 sentences) that we can use to promote you as a featured artist, poet, designer, etc.*
Please submit a head shot photo (optional).

Browse Files

Cancelof
Please provide a description of your design, the lyrics for your song, or the title and theme of your original poem.
Please submit your design, song, or poem here. Designs need to be in ai, eps, or high resolution jpg format. Songs need to be MP3. Poems need to be docx or pdf.

Browse Files
Name your file as TBTN_DESIGN_YOURNAME, TBTN_SONG_YOURNAME, or TBTN_POEM_YOURNAME. If you are sending more than 1, please add the number of each at the end. Cancelof
Do you want to receive the TBTN newsletter as a TBTN Fan (free)?

YesNo
Enter your Facebook Account, if you have one:
Enter your Twitter Account, if you have one:
Enter your LinkedIn Account, if you have one:
Enter your Instagram Account, if you have one:
Follow us!
Artistic Works and/or Service Contributions Release Consent and Agreement

I hereby irrevocably agree and consent that Take Back The Night Foundation, and any affiliated organizations, (hereinafter collectively referred to as ORGANIZATION), may use all or part of the artistic works and/or service contributions (hereinafter collectively referred to as CONTRIBUTIONS); including, but not limited to photographs, videos, audio recordings, images, written works, artwork, podcasts, presentations, webinars, PowerPoint slides; created or provided by me and submitted through this form as a contribution to ORGANIZATION for any purpose of their choosing. ORGANIZATION has the right to use my CONTRIBUTIONS in any way ORGANIZATION sees fit. I shall not now—nor at any future time—be entitled to, nor shall I make claim to: 1) any wages, royalties or compensation of any kind for my CONTRIBUTIONS as used by ORGANIZATION; and/or 2) ownership or executive interests in my CONTRIBUTIONS as used by ORGANIZATION. The rights granted herein to ORGANIZATION are perpetual, worldwide, and include the use of my CONTRIBUTIONS in any print, sound, digital or electronic medium available now or that may become available in the future including, but not limited to, print, broadcast, web, television, radio, application, programming, the Internet, CD, DVD, and any other format or location.

No other agreement, statement, or promise not contained or referenced in this “Artistic Works and/or Service Contributions Release Consent and Agreement” shall be valid or binding. ORGANIZATION is not obliged to make any use of my CONTRIBUTIONS or exercise any of the rights granted to them by this release.

All rights granted herein, by me to ORGANIZATION, as well as all terms of this agreement and consent, shall insure to the benefit of the successors and assigns of ORGANIZATION.

I understand that there will not be a way to track how my CONTRIBUTIONS are used. ORGANIZATION is not held liable for misuse or editing of my CONTRIBUTIONS. I understand that my CONTRIBUTIONS may be distributed to other institutions and organizations for use in events or other purposes. I understand that my name will be listed as the author of my CONTRIBUTIONS, with the rights provided to use it by ORGANIZATION.
Are you of legal consenting age or acting with permission of a parent or legal guardian?*

I am at least 18 years of age, and am acting in my capacity as a legal adult in signing and agreeing to the terms of this form submission.I am less than 18 years of age, and as a minor have the permission of a parent or legal guardian to sign and agree to the terms of this form submission.
Please read the terms and conditions above and respond below:*

I hereby agree to the terms of this Submission, Release and Hold Harmless Agreement.
Today's Date*

MonthDayYear
Date
Please sign to agree to the terms:*

Clear
Please have your parent/guardian sign to agree to the terms:*

Clear
Should be Empty: