Share Your Story

Share Your Story

Thank you for your courage in sharing your story. Please read and agree to the terms and conditions before submitting your story. We receive many submissions and are not able to publish them all, but greatly appreciate your strength in completing this form to share your story.
Are you of legal consenting age or acting with permission of a parent or legal guardian? *

I am at least 18 years of age, and am acting in my capacity as a legal adult in signing and agreeing to the terms of this form submission. I am less than 18 years of age, and as a minor have the permission of a parent or legal guardian to sign and agree to the terms of this form submission.
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province
Email *

Confirmation Email example@example.com
Age *
Your Story: *
If you would like to upload a photo of yourself, please do so here.
Would you be interested in sharing your story during a Virtual TBTNF Event? *

Yes No
Do you want to be a TBTN Fan (free)? *

Yes No
Terms and Conditions for Submission, Release, and Hold Harmless

I hereby irrevocably agree and consent that the Take Back The Night Foundation, commonly referred to as “Take Back the Night” or “TBTN” (ORGANIZATION), may use all or part of my submissions with this form (SUBMISSION) as a contribution and donation to the Foundation for any purpose of their choosing. ORGANIZATION has the right to use my SUBMISSION in any way ORGANIZATION sees fit. I shall not now—nor at any future time—be entitled to, nor shall I make claim to: 1) any wages, royalties or compensation of any kind for my SUBMISSION as used by ORGANIZATION; and/or 2) ownership or executive interests in my SUBMISSION as I am donating ownership and all rights for my SUBMISSION to ORGANIZATION. The rights granted herein to ORGANIZATION are perpetual, worldwide, and include the use of my SUBMISSION in any print, sound, digital or electronic medium available now or that may become available in the future. I am voluntarily choosing to give all ownership rights to my SUBMISSION to ORGANIZATION. ORGANIZATION is not obliged to make any use of my SUBMISSION or exercise any of the rights granted to them by this release. All rights granted herein, by me to ORGANIZATION, as well as all terms of this agreement and consent, shall insure to the benefit of the successors and assigns of ORGANIZATION.

I understand that my SUBMISSION will not be posted if it is not appropriate in the opinion of the ORGANIZATION for a general audience. I understand that my SUBMISSION may be altered if it contains names of specific individuals or places. I understand that my SUBMISSION will not be posted if it contains any information that is considered to be potentially harmful or against any laws, policies or ordinance with which ORGANIZATION must comply. I agree to hold ORGANIZATION harmless for any consequences I may incur for submitting my story.
Please read the terms and conditions above and respond below: *

I hereby agree to the terms of this Submission, Release and Hold Harmless Agreement. I do not agree to the terms of this Submission, Release and Hold Harmless Agreement.
Please sign to agree to the terms above: *

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