Testimonial Submission Form
Thank you for your interest in submitting a testimonial video for Song for Charlie's social media platforms (Facebook, Instagram, TikTok, Snapchat, Youtube, Twitter). Our team will be reviewing all videos before they are posted. Submitting your video and this form, does not guarantee that your video will be used.
Name
*
First Name
Last Name
Email
*
[email protected]
Phone Number
-
Area Code
Phone Number
Where are you from?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How old are you?
Relation to the victim?
Name of victim?
Where was/is the victim from? (City/State)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age of victim?
Is the victim deseased?
Yes
No
Date they passed away
Drug they thought they were purchasing?
How did they purchase the drug?
Snapchat
Instagram
Facebook
Twitter
Dealer in person
Friend
Family
Other
What are your social media handles?
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mp3, mp4, mov files only.
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Video Consent and Release
I hereby give my consent to Song for Charlie, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet), without expectation of compensation or other remuneration, now or in the future. This consent is given in perpetuity, and does not require prior approval by me. This consent includes, but is not limited to: (Check where applicable)
*
Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
Permission to use my name; and
Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.
By submitting this form, I hereby waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears. In addition, I attest that any statements I make during my appearance are true and accurate.
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