Weathering Portrait Interest Form

Weathering Portrait Interest Form

Thank you for your interest in participating in our Fibroid Awareness Portrait Project. This initiative seeks to highlight the experiences, strength, and stories of women of color living with fibroids in Atlanta. Your participation will help amplify awareness, build community, and inspire others through visual storytelling.
Instructions

Please complete all required fields marked with an asterisk (*).Review the Photo Release Statement carefully before submitting.Once submitted, our team will contact you with next steps, scheduling, and additional details.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Your Connection to Fibroid Awareness
Have you been diagnosed with fibroids?*

YesNo
What would you like people to understand about fibroids and women of color? (Short response)*
Are you open to sharing your personal story alongside your portrait?*

YesNo
Portrait Interest
Why are you interested in participating in this portrait project?*
Do you have any preferences for your portrait setting (studio, outdoor, personal space, etc.)?*
Would you be comfortable with your portrait being used in: (Check all that apply)*

Educational materialsAwareness campaigns (digital & print)Social MediaCommunity events/exhibits
Photo Release Consent

By signing below, I grant permission for my photograph, likeness, and any statements I provide to be used by Kahiah Polidore for the purposes of fibroid awareness, education, advocacy, and community engagement. I understand that my image may be used in printed materials, digital media, exhibitions, and promotional campaigns. I acknowledge that: I will not receive financial compensation for the use of my image. My participation is voluntary, and I may withdraw consent in writing at any time. The photographer and organization will handle my image with care and respect.
I have read and agree to the above photo release statement.
Signature*

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Weathering Portrait Interest Form

Instructions

Your Connection to Fibroid Awareness

Portrait Interest

Photo Release Consent