1 Story2 Information3 ConsentYour StoryStory Title Story BodyPlease share your story in 300 words or less.Upload images or other files to include with this storyPlease upload at least one high quality image Drop files here or What is your story about?Check all that apply Child Care Education Healthcare Paid Family Leave Paid Sick Days Wages/Jobs Workplace Issues Save and Continue LaterYour InformationName First Last Email PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Save and Continue LaterConsentI authorize Holland Children’s Institute to record and edit into the Nebraska Story Bank (the “Project”) and related materials such as my name, likeness, image, voice, written testimony, and interview (the “Media”). Holland Children’s Institute may use and authorize others to use all or parts of the Media. Holland Children’s Institute, its successors and assigns shall own all right, title and interest, including copyright, in and to the Project, including the Media, to be used without limitation as Holland Children’s Institute shall in its sole discretion determine.* YesI consent to Holland Children’s Institute sharing my story and attest that the story I am submitting is true to best of my knowledge and recollection.* YesDigital Signature*By typing your name in the box, you adopt this as your digital signature.Date* PhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.