Name *

First Name

Last Name

ADULT PERMISSION INFORMATION: I am 18 years old or older and I give Embraced & the Sam In A Can production team permission to use my image, my likeness, and my story to be used for, by, and with in Embraced project . *

Yes, I give full permission to Embraced and the production company, Sam In A Can, who is overseeing the project and to the sponsoring nonprofit Hope & Rescue Foundation to use my story that I am submitting. I understand my story may be featured in their documentary, on their website, in their social media channels, or as part of their fundraising efforts for awareness of FASD and the Embraced project.

I give partial permission to Embraced and the production company, Sam In A Can, who is overseeing the project and to the sponsoring nonprofit Hope & Rescue Foundation to review my story that I am submitting. However, I would like to be contacted before it is used in a public way for the Embraced project.

YOUTH/MINOR PERMISSION INFORMATION: I am the legal guardian to a child UNDER 18 years old who would like to submit their story and I give Embraced & the Sam In A Can production team permission to use their image, their likeness, and their story to be used for, by, and with in Embraced project. NOTE: Someone from the Embraced team will contact you before any story will be used publicly. *

Yes, I give permission for the Embraced team to review the story submitted by the minor that I am a legal guardian for to be considered for partial use in the Embraced project.

I give permission for the Embraced team to review the story submitted by the minor that I am a legal guardian for to be considered for some of the Embraced public awareness outreach.

I also give permission for my story to be shared on the Red Shoes Rock (a partner) website and Facebook page as well. *

Yes

No