One Million Kids For Equality

I identify as...*
How old are you?*
- I am not 18 years old yet
- I am at least 18 years old.
Your Story*
Have you shared your story with anyone else?*
- Yes, I have shared my story with others.
- No, I have not shared my story with others.
I've shared my story with...*

My Parent(s) and/or Guardian(s)...*
- are aware of my situation, but I would only like to share my initials for this story.
- are NOT aware of my situation and I would like to share only my initials for this story.
- are aware of my situation and they have agreed to let me share my full name and contact information for this story.
My initials are*
Date of Birth*
Would you like to leave a picture of yourself with your story?*
- Yes! I DO want to leave a picture of myself with my story.
- No. I DO NOT want to leave a picture of myself with my story.
First Name*
Last Name*
Your Email*
Upload Your Picture*
Accepted file types: jpg, gif, png.

Parent First Name*
Parent Last Name*
Parent/Guardian's Phone*
Release and Authorization*
- I agree to the forgoing authorization and release.
By checking the box above, I acknowledge that I have read the foregoing release and authorize One Million Kids for Equality to use, reproduce, and/or publish photographs, videos and/or writings that may pertain to me, including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, media releases, recruitment materials, advertising, charitable solicitations, PSA’s or for other related endeavors. This material may also appear on the One Million Kids for Equality website. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Therefore, One Million Kids for Equality may publish materials, use my name, photograph, and/or make reference to me in any manner that One Million Kids for Equality deems appropriate.
First Name*
Last Name*
Address*
City State

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