Name *

First Name

Last Name

Author *

Mother

Father

Partner

Birthing Person

Grandmother

Grandfather

Sister

Friend

Other

Birth Story Type *

Vaginal Birth

Cesarean Birth

Water Birth

Hospital Birth

Home Birth

Birth Center Birth

Midwife Provider

Family Doctor Provider

OBGYN Provider

I Release of my story (terms & conditions) *

By signing this release form, I authorize The Birth Monologues [Mother Tree Int’l LLC, to use the following personal information: (1) My picture – including photographic, motion picture, and electronic (video) images. (2) My voice – including sound and video recordings. (3) My story—including song, poem, essay or written word. I hereby grant to The Birth Monologues [Mother Tree Int’l LLC, its subsidiaries, li- censees, successors and assigns, the right to use, publish, and reproduce, for all pur- poses, my name, pictures of me in film or electronic (video) form, sound and video recordings of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media including, without limitation, cable and broadcast television and the Internet, and for exhibition, distribution, promotion, advertis- ing, sale, press conferences, meetings, hearings, educational conferences and in brochures and other print media. This permission extends to all languages, media, for- mats and markets now known or hereafter devised. This permission shall continue for- ever unless I revoke the permission in writing. I further grantThe Birth Monologues [Mother Tree Int’l LLC all right, title, and interest that I may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grantThe Birth Monologues [Mother Tree Int’l LLC the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for marketing, communica- tions, or advertising purposes, as it deems fit. I hereby waive the right to receive any payment for signing this release and waive the right to receive any payment forThe Birth Monologues [Mother Tree Int’l LLC use of any of the material described above for any of the purposes authorized by this release. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer generated scanned image and other electronic media that may be used in conjunction therewith or to approve the eventual use that it might be applied. I acknowledge that I have read the foregoing and I fully understand the contents.

YES I agree to the release terms and conditions

NO I don't agree. Please contact me