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) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The above checked items can be used in the following: (Check all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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My Abortion Pill Reversal Story

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Optional Information

Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Child's Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Agreement

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Release Form

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) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Other (describe) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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The above checked items can be used in the following: (Check all that apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Other (describe) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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My Abortion Pill Reversal Story

My Story {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Optional Information

Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Child's Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Child's Sex {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Photo Upload {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}
{ binding firstError.message }
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Agreement

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Electronic Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Comments or Concerns: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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