Inspiring Teen Moms Day Approval Form

If you are currently a teen mom or have been a teen mom, YOU inspire us! It is because of you, and the LORD’s leading, that we do what we do. We want the whole world to know about you and your courageous efforts as a teen mom.

That said, we created a Teen Mom Honor Wall on our website to display names of teen moms throughout the nation/world. We would love to honor you by displaying your name.

To give us permission to add you to the Teen Mom Honor Wall, please fill out the following information:

NAME*

First NameLast Name

YEAR*

List the year you gave birth to your child who made you a teen mom.

If we need to contact you, please check how we can best reach you.*

Email (If checked, please provide your email address below.)Phone (If checked, please provide your phone number below.)

Email Address

Phone Number

Please check one:*

I am a current teen mom that attends a TMC ProgramI am a current teen mom, but I do not attend a TMC ProgramI was a teen mom in the past and participated in a TMC ProgramI was a teen mom in the past, but was not part of a TMC Program

How did you hear about this honor wall?*

I hereby authorize and release Teen Mother Choices International (TMCI), its successors and assigns, to reproduce, circulate and use my likeness, as well as my recorded statements, for promotion, education, fundraising, and advertising in connection with its business.

I understand that my action is voluntary and in no way necessary to receive or continue to receive services from TMCI.

I understand this media consent and release is effective immediately.

I, therefore, agree to hold harmless and to release from liability TMCI with respect to any and all claims or causes of action of any kind arising from or in any way related to information being released about myself.

Please check one.*

I consent to the above.I do not consent to the above.

Today's Date*

Date

Your Signature*

Teen Mother Choices International 2024