Breech Birth Podcast - Consent and Survey Form

Breech Birth Podcast - Consent and Survey Form

Please read the following consent statement carefully. You will be asked to share your birth story, which may be used publicly. Additionally, there are survey questions at the end of this form.
Full Name of the Participant*

First NameLast Name
Thank you for your interest in sharing your story with the Breech Birth Podcast, a podcast dedicated to amplifying women's voices around breech birth experiences. By completing this form, you are voluntarily submitting information that may be used in podcast episodes, social media content, You Tube channel or related materials. Your participation is entirely voluntary, and you may choose to remain anonymous or be identified by your first name, pseudonym, or full name — according to your preference. You have the right to withdraw your story at any time before it is published. We may contact you for clarification or follow-up if needed. Your responses will be treated with respect and stored securely. Submitting this form does not guarantee inclusion in an episode, but all stories are appreciated and deeply valued. By completing this form, you agree to not identify any health care worker or birth worker e.g. doula, photographer etc. by name whilst sharing your story to protect their identity. PLEASE SELECT ONE OF THE FOLLOWING OPTIONS:*

I have read the above and consent to share my breech birth story for use in the podcast and related materials.I have read the above and do not consent to share my breech birth story for use in the podcast and related materials.
Enter your email address.*
Do you wish to remain anonymous? If so, please share a pseudonym.*
What year was your baby born?*
Where were you located at the time?*
eg. Sydney NSW Australia
What kind of care did you receive during pregnancy, labour, and birth?*
eg. hospital care, MGP, private midwifery, private obstetrician, freebirth with/without antenatal care
Was this a surprise or planned breech birth?*
How was your breech baby born?*
eg. vaginal, caesarean
Thank you for completing the Breech Birth Podcast consent and questionaire. We will be in touch as soon as possible.
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