Share Your Story - Who Am I Really Podcast

First Name

Last Name

Where do you live now?

Website URL

Your mobile number

Your Instagram ID?

Your Facebook ID?

How much do you want to share?

I'm open to sharing my whole story Could we keep a few parts confidential pls? I'd really like to remain anonymous please.

Website or Links to your story

Brief background on your childhood in adoption*

A few words about your reunification:

Upload a photo that's meaningful to you (optional)

Please check the box below to confirm that: I have your permission to use your name, likeness, and any information you share in this form or that is captured during any audio or video recording is freely shareable with the “Who Am I Really?” podcast community via social media and internet online platforms or apps. You understand that the edited version of this recording will be included in a future episode of the “Who Am I Really?” podcast. The “Who Am I Really?” podcast is distributed worldwide to our audience via multiple platforms including, but not limited to podcast platforms, YouTube channel, occasionally through other audio and/or video platforms, and via social media. Additionally, you waive any right to royalties or other compensation arising or related to the use of your image or recording. You also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes: • conference presentations • educational presentations or courses • informational presentations • on-line educational courses • educational videos We both agree I am the owner of all of the rights to this recording and may edit for time or clarity and distribute it electronically and digitally. You acknowledge that limited portions of your story from your recorded interview may be used in articles or books as quotes, which will of course occur with the appropriate referencing. You hereby grant permission to the rights of your image, likeness and sound of your voice as recorded on audio or video without payment or any other consideration. You understand that your image may be edited (usually for size limitations online), copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein your likeness appears. By acknowledging this release you understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. By acknowledging this form I confirm that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes. Please check the box below to acknowledge you agree. Thank you!

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