NJDHSCO1.Story Submission Form

Story Submission Form

Email address

Name (First Name Last Name)

Phone number(s): If you would prefer us contacting you by phone instead

Home

Office

Cell

Phone No

Organization (If applicable)

Your Story

Add your Story 500 words or less

You can upload Stories by clicking on Select files (Optional) 100 MB or less: Ex: word documents, pdf files, images etc

Please add youtube video links if applicable 3 mins or less

New Jersey Governor’s Council on Mental Health Stigma Release:

Photo, Video, Interview and Website

I, hereby authorize the New Jersey Governor’s Council on Mental Health Stigma and its assignees to utilize my personal information and likeness, including, but not limited to photographs, names, videos, voice, interviews and postings on its website (hereinafter “Personal Likeness”). I understand that if I share specific clinical information for a publication and/or in a video interview and/or for posting on its website, this signed release form serves as permission for the New Jersey Governor’s Council on Mental Health Stigma to release this information to the public in its publications and/or videos.

I further authorize the New Jersey Governor’s Council on Mental Health Stigma to copyright, use and publish my and/or my minor child’s story and/or Personal Likeness in print and/or electronic media, including but not limited to “publications, videos, Zoom meetings and on its website, as well as outside media (e.g., newspapers, websites and professional journals/magazines). The New Jersey Governor’s Council on Mental Health Stigma may further use such Personal Likeness, with or without crediting me for any lawful purpose, including, but not limited to educational campaigns, promotion of events, news reporting, and web/Internet content.

I understand the nature of this authorization and have been informed that I have the right to revoke consent at any time by written communication to the New Jersey Governor’s Council on Mental Health Stigma

Signature

Date