Share Your Story

Name *

First Name

Last Name

Phone *

(###)

###

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How can we refer to you in the story? *

You can use my full name.

Please use only my first name.

Please use my family name. (ie. Smith Family)

I wish to remain anonymous.

Would you consent to a further interview? *

Yes

No

Story and Photo Release Agreement *

I grant Leg Up Farm permission to use my story and/or photo on the website or social media and/or in fundraising or marketing materials, such as the e-newsletter.

Yes

No