MADD National Victim Services
Victim/Survivor Stories Questionnaire

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Thank you for allowing MADD to share your story to bring about awareness and prevention.  The form is about 4 pages long, however, only the red asterisk portions are required. There are several questions that ask for more detail as well as a place you can add photos (if you want to do either).  The detailed questions aren’t required, but may mean that MADD would need to reach out for more detail at a later time.  Thank you once again for being a part of MADD’s mission to end drunk driving, help fight drugged driving, serve the victims of these violent crimes and prevent underage drinking.

Your full name:


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We would love for you to include a photo of the person who was involved in the crash. 



CONSENT FORM FOR RELEASE OF MATERIALS

In consideration of our mutual desire to help educate the public about underage drinking and the dangers of drinking and driving, I hereby authorize Mothers Against Drunk Driving (MADD) National Office, State Office, Local Chapter, and third parties associated with MADD to use my name, likeness, image, voice, or appearance as such may be embodied in any pictures, photos, video recordings, audio recordings, audiotapes, digital images, stories, and the like, taken or made by or on behalf of MADD, or submitted by me to MADD  (collectively, the “Materials”) for both commercial and non-commercial uses, including, but not limited to public service announcements (PSAs), social media posts, blogs brochures, publications, photoboards, billboards, media campaigns, radio or television interviews or other promotions, marketing, or fundraising campaigns.

I understand that MADD will use the Materials for an unspecified period of time. 

I release MADD, its officers, directors, employees and volunteers from all liability that may arise in connection with this release.

I understand that MADD will provide no monetary compensation for Materials used.

By entering your name below, you swear and affirm that you are the individual completing the questionnaire, that you have the authority to complete and submit this questionnaire and any attachments, and that the information you have provided is true and correct to the best of your knowledge.
Thank you for sharing your story with MADD.  If we can do anything to help you during your healing journey, please contact 877-MADD-HELP.