Black Birth Worker Wednesday Info Form

Thank you for your interest in being highlighted on Dem Black Mamas Podcast instagram page for Black Birth Worker Wednesday. We began Black Birth Worker Wednesday in June of 2023. Our intention is to use our platform to uplift the ancestral practices of birth work, call attention to the Black Maternal Health Movement & uplift the work of current birth workers and Black maternal health advocates and creatives. Ultimately, we want to see ourselves and each other in this work to build and be inspired. Your submissions will help us continue this mission. We are looking for individuals, organizations, businesses, initiatives/causes, art/creative projects, events, etc., led by Black women who focus on Black women.

Thank You!

IMPORTANT INFO

Forms will be reviewed on th 5th of each month to be featured the following month. For example, if you'd like to be featured in November, complete the form by October 5th.
If selected as a feature, you will be notified at least a week in advance.
Completing the form doesn't guarantee a feature.
If you have any questions, please email us directly at magic@demblackmamas.com.

Name of Contact Person*

First NameLast Name

Pronouns

E-mail of Contact Person*

example@example.com

Name of person, organization, business, initiative, campaign and/or artistic endeavor being featured for Black Birth Worker Wednesday.*

If submitting as individual or for an individual, please let us know what pronouns to use.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Bio or mission/intention of organization, business, campaign, initiative and/or artistic endeavor.*

Information you'd like us to include about you or your business, organization, initiative, campaign and/or artistic endeavor.*

Website

Instagram personal page, initiative, business, organization, or Artistic Endeavor (Please put the entire link to social media, not just the name/handle.) We are only active on Instagram. *

Ex. https://www.instagram.com/name

List upcoming events and/or book/project releases here. Please include description & website for more information.

Please check what type of file you'll be uploading.*

PicturesReelVideo (outside reel dimensions)

Upload photos or videos. PHOTOS: Please send more than one photo. If you are submitting as an individual, here are some suggestions: upload your favorite snapshot, headshot, and if you have any, pictures of yourself working as a birth worker. If you are submitting as an organization, here are suggestions: a group picture of your staff, a picture of the people you serve, and a picture of you actively doing birth work. A picture of your location (inside and outside). VIDEOS: Please be sure all videos are under 3 minutes and must be in mp4 format, preferably Instagram reel dimensions (1080x1920). Please DO NOT add/include music in your videos. You can just make music suggestions below.*

Browse Files

Music recommendations for your post.

If you would like to recommend someone for Black Birth Worker Wednesday, please list their contact information below.

How did you hear about Black Birth Worker Wednesday?*

Would you like to be added to our email list? We send about four emails a month.*

YesNo

Would you like to be added to our text community?*

YesNo

RELEASE

The above-named does hereby consent to DEM BLACK MAMAS PODCAST the distribution of reproduction(s) of the media (video and/or pictures) as part of the campaign entitled BLACK BIRTH WORKER WEDNESDAY (herein after referred to as the "Campaign") and freely gives a non-transferable perpetual license to use, record, and publish the program.

The above-named understands and agrees that he/she shall receive no compensation for appearances on and participation in the Campaign.

The above name, likeness, and photograph may be used in connection with the Campaign and in advertising and promotional material for the Campaign, but not as an endorsement of any product or service.

The above-named retains the right to all of the content they created for the Campaign.

If the above-named wants to revoke any grant made in this agreement, the above-named will send notice to DEM BLACK MAMAS PODCAST 14 days before revoking.

The above-named hereby releases and discharges DEM BLACK MAMAS PODCAST from any and all liability arising out of or in connection with the making, producing, reproducing, processing, exhibiting, distributing, publishing, transmitting by any means or otherwise using the above-mentioned campaign.

Signature *

Date

BLACK BIRTH WORKER WEDNESDAY FEATURE INTEREST FORM