Grants Department

STORYTELLING & MEDIA RELEASE FORM

Purpose

Sharing your story helps Walking With Anthony demonstrate impact and inspire donors and other survivors. Participation is entirely voluntary and will not affect your grant or eligibility for support.

Full Name *

Email *

Your Experience

What does receiving this grant make possible for you right now? *

If you could speak directly to the donors who made this grant possible, what would you want them to know? *

Is there anything else you would like to share about your journey? (optional)

Photos (optional)

Please upload 1–3 photos you are comfortable with with Walking With Anthony using for educational, fundraising, or promotional purposes.

Name & Likeness Release

I understand:
• Participation is voluntary
• My grant is not dependent on participation
• I may withdraw consent at any time by contacting Walking With Anthony

By checking below, I grant Walking With Anthony permission to use my name, likeness, voice, photographs, video, and written statements for educational, fundraising, marketing, and promotional purposes, including digital, print, and event materials. *

I agree to the Name & Likeness Release

Date *

Digital Signature *

Clear