Release Form

Personal Story/Testimony/Photograph

Please note that each individual over the age of 18 who appears in a photograph or is mention by name in a story should submit a separate release. For example, if five individuals are in a "group" photograph, please ask each individual to submit a separate release.

I agree to allow Heartbeat International (Heartbeat), who owns and operates Abortion Pill Rescue, to reproduce, circulate and/or use my personal story, testimony, and/or photograph(s)..

I agree to waive any and all rights, claims or actions that I may have against Heartbeat arising from the publication and use of my story, testimony, and/or photograph(s), as I have designated below. I hereby release Heartbeat and any of its associated or affiliated offices, their directors, officers, agents, employees and volunteers, from claims of every kind on account of such use.

I also warrant that I hold all relevant rights to the photograph I have submitted.

Permissions

I give permission to HBI to use any of the following: (Check all that apply)

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Other (describe)

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The above checked items can be used in the following: (Check all that apply)

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Other (describe)

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My Abortion Pill Reversal Story

My Story

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Optional Information

Child's Name

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Child's Birth Date

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Child's Sex

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Photo Upload

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Agreement

Name

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Phone

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Electronic Signature

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Date

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Comments or Concerns: