PersonalStoryReleaseForm - WellSpring Center For Hope

WellSpring Center For Hope

Empowering Families to Live Healthier & Happier Lives

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Personal Story & Release Form

DV 101

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Permission to Release Information,
Personal Stories, Photographs, or Videotapes

Whether you are a "Survivor" of Domestic Violence or a "Victim" of Domestic Violence, you can reach out and help others who are also suffering.

By sharing your personal story, photographs, or videotapes and giving us permission to use them in our news media and our educational classes you will help a man, woman or child understand that they are not alone. That there are others who have experienced abuse and have become "Survivors".

Partner with us to end Domestic Violence. Share your personal story here.

Thank you and God Bless You.



Name:
Address:
City:
State:
Zipcode:
Phone #:

I give permission to WellSpring Center For Hope (Check one or more)

	To release information concerning me to the news media.
	To release my story, photos, or videos to the news media or use them for educational purposes.
	To release information, personal stories, photos or videos with the following conditions or exceptions that I have listed in the box below. (If no restrictions, please write "None.")


I understand the news media may release this information to the public. I understand my name and picture, if taken, may be used publicly. I release WellSpring Center For Hope from all responsibilities for the actual use of the pictures, video tape, or the information about me.

Name:
(Printed name here becomes a signature for release of information.)



Special circumstances: I am consenting for the above named person because:

	The subject of the information, personal story, photographs or video tapes is a MINOR and I am their legal guardian.
	The person is physically unable to fill out this form and I am doing so at their request.

Guardian/Consenter's Name:
(Printed name here becomes a signature for release of informtion.)

Your relationship to the above named person:



Your Personal Story
In the space below, please share your personal story of Domestic Violence. Your story will be shared with other victims of Domestic Violence in the hopes that they will see themselves in your story and take the necessary steps to become a Survivor of Domestic Violence.

WellSpring Center For Hope
P.O. Box 368800
Chicago, IL 60636

Monday - Friday 8:30 a.m. - 4:30 p.m.
773-723-2119

Email Us:

wellspringctrhope1@yahoo.com