Please print this form and FAX it to The Witnessing Project at 
617-332-2522 (United States)

I, _________________________________, give (Name________________________) permission to write an account of my experience as a witness to violence and violation. I understand that the account will appear on the World Wide Web and may be used for other educational purposes, for instance in writings or teaching. I also understand that Kaethe Weingarten of the Witnessing Project will hold the copyright of this account.

I do want my name to be attached to this account Yes_____ No ____

Name __________________________________

Date ___________________________________

Address_________________________________

_______________________________________

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