Soulful Echoes

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

I am ____ *

the child

a sibling

a parent

a relative

a friend

a teacher

a child care provider

a social worker

a family law professional

a court advocate

other

Issues at play: *

Domestic Violence / Abuse / Neglect

Substance Abuse (Alcohol/Drugs)

Financial Struggles

At Risk for Homelessness

Not Applicable

Do you understand that by checking the consent checkbox, you will give permission for us to be able to collect quotes from your story to use internally and/or in campaigns without any identifiable details. Signing this form does not give us permission to share anything publicly with identifiable details. *

Yes

Would you like to keep in touch for further involvement?* E.g., Working together to share your story publicly and/or participating in other activities. *

Yes

No

I certify that I am not a minor, and I am free and able of giving my own consent. *

Yes

No

I declare under penalty of perjury that the foregoing written story I am submitting is true and correct. *

In order for us to share written testimonials, this legal DECLARATION OF FACT must be completed by you. This ensures your submission is truthful and factual.

I agree to the above declaration.

I disagree to the above declaration.

I hereby release this website and its owners from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss or damage due to my submitted testimony. *

I agree to the above declaration.

I disagree to the above declaration.

Do we have your consent to contact you and use your contact details when it's time to submit witness slips for the legislative bill? *

Yes

No

Maybe (We will reach out to you when it's time)

Do you consent to your story being shared publicly? *

Yes and you can use my first name.

Yes, Anonymously.

No.

I assign rights of the submission to the website so the website can use it. *

I agree to the above declaration.

I disagree to the above declaration.