Story Sharing

Thank you for sharing your journey with us. To protect your privacy, all name, time and location will be changed through our podcast/blog. We appreciate for your understanding on this matter.

First Name

Last Name

Address

Phone Number

What is your child(ren)'s age?

What story do you want to share with us? (each story would require a submission, you can tell us as many stories as you want)

What kind of feedback are you looking for from our blog/podcast?

Where do you want us to broadcast your story?

Blog Podcast Both

Are you safe at this moment

Yes No I don't know

I consent to myself and/or my child story by or for The Circle Of Ma with the understanding that the The Circle Of Ma may use the materials for marketing, publicity and/or fundraising purposes now or in the future. I understand and accept that The Circle Of Ma, may use my story for the interviews, photographs and/or videotape for any way that they deem fit for events, Public Service Announcements and/or promotions including but not limited to TV, Internet, promotion, illustration, advertising, editorial and publication. I am hereby notified that should I have any concerns about the terms on this page, or my ability to give consent, I am encouraged to seek independent advice or legal advice on the matter.

I agree to give my consent to the terms and conditions