Consent Form

Sharing your experiences inspires providers, uplifts parents and supports our mission.

Please submit this form to grant ZERO TO THREE permission to use your stories, photographs, video, audio or other media for its organizational and mission-oriented purposes. For the purposes of this consent form, “story” refers to all media types.

Why we are asking you to share your story: Stories are powerful. They can show the reality of what children, caregivers and providers face; what’s working and what isn’t; and what your hopes are for the future in ways that resonate with policymakers, advocates and donors who can create lasting change for young children.

Your rights to your story:

You may see how your story will be used.
You may request updates to your story.
You may revoke your consent at any time. To do so, email stories@zerotothree.org. After you revoke consent, we will not use your story in communications from that point forward. We will do our best to retract already published images and stories, but please understand that we may not be able to remove all such instances.
You may contact us at any time at stories@zerotothree.org with any questions or concerns.

By signing this release form, you are granting ZERO TO THREE the exclusive right to use, adapt, modify, reproduce, distribute, translate, promote and publicly display your shared story in perpetuity.

This includes, without limitation, the ability to reproduce, distribute or sell the Content, in whole or in part, in hard or electronic copy, including in print, CD, DVD, broadcast and in any other medium now known, including on websites, videos, and on other public online forums (email, social networking platforms, newsletters, etc.), or hereafter invented.

By signing this release form, you acknowledge that ZERO TO THREE owns all content and works created or collected by ZERO TO THREE and/or by its affiliates, agents, successors and/or assigns, that use, are based on or incorporate the content or my Personal Information. (Your Personal Information — which means name, appearance, likeness, statements and other limited biographical information — may be used, adapted, modified, reproduced, distributed and publicly displayed by ZERO TO THREE in connection with the story in any medium now known or hereafter invented.)

If you understand, agree and consent, please provide the information below, sign your full name and include the date.