Share Your Story

Share Your Story

Thank you for your courage in sharing your story. Please read and agree to the terms and conditions below before submitting this form. 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.
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Would you be interested in sharing your story during a Virtual Take Back The Night Event?*

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Would you be interested in sharing your story on the Dear Katie podcast? (Learn more at https://katiekoestner.com/podcast/)*

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To share your story on the Dear Katie podcast, you'll need to complete a separate application. The application link will be available on the Thank You page after you submit this form and will be emailed to you as well.
Would you be willing to have your story shared with the Take Back The Night Newsletter Fans & Friends?*

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Do you want to receive the TBTN Newsletter and become a Fan (free)?*

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Terms and Conditions for Submission

Please review these terms carefully as they govern your use of this form and the information you provide. If you do not agree with any term or condition, please do not complete this form.

I hereby irrevocably agree and consent that the Take Back The Night Foundation (hereinafter, ORGANIZATION), may use all or part of my submissions with this form (hereinafter, SUBMISSION) as a contribution and/or donation to the ORGANIZATION for any purpose of its choosing. ORGANIZATION has the right to use my SUBMISSION 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 SUBMISSION as used by ORGANIZATION; and/or 2) ownership or executive interests in my SUBMISSION as I am donating ownership and all rights for my SUBMISSION to ORGANIZATION. The rights granted herein to ORGANIZATION are perpetual, worldwide, and include the use of my SUBMISSION in any print, sound, video, digital or any other medium available now or that may become available in the future. I am voluntarily choosing to give all ownership rights to my SUBMISSION to ORGANIZATION. ORGANIZATION is not obliged to make any use of my SUBMISSION 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 release and discharge ORGANIZATION from any and all claims and demands that may arise out of or in connection with the use of my SUBMISSION, including without limitation any and all claims for libel or violation of any right of publicity or privacy. This authorization and release shall also inure to the benefit of the heirs, legal representatives, licensees, and assigns of ORGANIZATION. I agree to hold ORGANIZATION harmless for any consequences I may incur for my SUBMISSION. I am a legally competent adult and have the right to contract in my own name. If I am a minor, I have permission from my parent or legal guardian to complete this form. I have read these terms and conditions and fully understand them. This release shall be binding upon me and my heirs, legal representatives, and assigns.
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