2018 - 2023 First Breath Stories

Share Your Success Story

Congratulations for all the progress you have made for your health, and thank you so much for sharing your story with us. Your experiences will help and inspire others trying to quit!

1. You have two options for sharing your story about stopping or reducing your tobacco, alcohol, or other substance use. Which would you prefer to use? (Whichever option you prefer, you'll receive one gift card for sharing your story. Please allow up to two weeks for gift card to be mailed.) *This question is required.

Option 1: Create a short video (Even 30 seconds recorded on your phone is great!).

Ideas of things to include:
-When/Why did you decide to stop/reduce your use of tobacco, alcohol, or other substances?
-What specific things did you do to stop or cut down?
-What benefits have you noticed?
-What advice do you have for others trying to stop or reduce their use of tobacco, alcohol, or other substances?

Upload your video here: *This question is required.

File: {{filename}} delete

Option 2: Written Testimonial & Optional Photo:

Write/type your quit smoking story here (minimum requirement of 150 words):

Ideas of things to include:
-When/Why did you decide to stop/reduce your use of tobacco, alcohol, or other substances?
-What specific things did you do to stop or cut down?
-What benefits have you noticed?
-What advice do you have for others trying to stop or reduce their use of tobacco, alcohol, or other substances? *This question is required.

Option 2: A picture is worth a thousand words! Submit your photo here: *This question is required.

File: {{filename}} delete

2. To be able to use your story in our materials, we need to have a model release filled out as well.
Please read the following paragraph and type your name in below to agree to the following:

I hereby grant to the Wisconsin Women’s Health Foundation’s First Breath Program the irrevocable and unrestricted right and permission to copyright and use, re-use, publish, and re-publish video or photographic portraits or pictures of me (or my minor child) or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any medium at its studios or elsewhere, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, or any other purpose whatsoever. I also consent to the use of any printed matter in conjunction therewith.

I hereby waive any right that I may have to inspect or approve the finished product or products and the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied.

I hereby release, discharge and agree to save harmless Wisconsin Women’s Health Foundation, its officers, directors, employees, legal representatives and assigns, and all persons acting under its permission or authority or those for whom it is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without any limitation any claims for libel or invasion of privacy.

I hereby warrant that I am of full age and have the right to contract in my own name or the legal right to execute on behalf of my minor child. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns.

If you agree, type your name below: *This question is required.

3. What is your first and last name?

4. How would you like to be identified? *This question is required.

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

5. What is YOUR Date of Birth?
(Format: MM/DD/YYYY, for example, August 16 1990 = 08/16/1990) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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6. Enter your address below and we will send you a thank you gift!
Street Address
City, State, Zip

7. FB ID