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SEND US YOUR STORY
Do you have a personal story to tell? Planned Parenthood is compiling a book of letters received from readers, clients, and friends. We believe it is time for the voices of teens to be heard. Send your story through the Talk Back section or by U.S. mail. Either way, we will need your permission to publish your story. Read the information below and fill in the responses. Print out this page, fill it out, sign it, and mail to us. You can submit your story by mail as well, or you can submit it through the Talk Back section.
NOTE: Please be advised that by signing and sending this form, Planned Parenthood will know your identification and user name.
PERMISSION FORM
I, _______________________, grant permission to Planned Parenthood Federation of America, Inc. (Planned Parenthood) to publish my letter (or parts of it) in a book to be prepared by Planned Parenthood and in any advertising or promotion of the book, any editions or revisions of it, in any language throughout the world, and in any form whether print or electronic (Internet) publication and in other media now known or unknown. I understand that the book and/or portions of it may be published in newspapers, magazines and other printed media, and may be released in other recorded media such as television or motion pictures, and I consent to such uses.
I understand that neither my name nor any identifying information will be used unless I agree in this form (below). I understand that I will not have the right to inspect the book. I agree not to make any claim relating to defamation, rights of privacy or publicity, confidentiality, copyright, or otherwise.
I grant permission to Planned Parenthood to publish my letter and agree to the terms described above. [ ] I agree.
My age: [ ] 18 or older [ ] Under 18
Very truly yours,
_________________________
User Name
_________________________
Name
_________________________
Date
_________________________
Address
_________________________
Telephone
You may use my name with my submission. [ ] Yes [ ] No
Note: If you are under 18, we will need the signed consent of your parent or legal guardian.
I am the parent or guardian of the minor named above and I agree to all terms outlined above.
SIGNATURE: _______________________________________ DATE:_________
PRINT NAME: _____________________________________________________
ADDRESS: _______________________________________________________
Please mail your story and permission form to:
teenwire.com
Planned Parenthood Federation of America
434 W 33 St
New York, NY 10001 |
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