Share Your Quit Story

I grant permission to Quit Partner, a program of the Minnesota Department of Health, to use the photograph and/or written story that I am submitting as part of or in connection with the production of Quit Partner publications and audio-visual presentations in any available format or medium.

I understand and agree that my written story, along with my photograph, first name, and city, may be publicly distributed or displayed in connection with Quit Partner informational programs and activities, including shared with mass media outlets and public health partners.

I waive any rights and release any claims or causes of action I may have to object to, prevent or seek damages for the release, publication or use of my photograph and/or written story under the Minnesota Data Practices Act (Minnesota Statutes, chapter 13) and any claims or causes of action I may have based on, arising from or related to invasion of privacy.

I am at least 18 years old and competent to sign this release.

We’ll never share your contact information or use it for anything else unless you give us permission

Quit Partner (a program of the Minnesota Department of Health) is asking you to provide the information on this form to collect stories it can use to inform and educate the public about Quit Partner programs and activities and to inspire others to quit smoking.

You are not legally required to submit any of the requested information and can refuse to do so. The only consequence of not supplying the information is that Quit Partner will not be able to share your story. You do not have to submit a story or any of the information requested on this form to receive Quit Partner services.

The story, photograph, first name, and city you submit will be made publicly available in Quit Partner publications or presentations, which may be made available online or shared with mass media outlets or local public health partners.

Quit Partner will not share your email address with persons other than those listed below, but may use your email address to contact you for more information.

The information you submit may also be released as follows:

• To employees of the Minnesota Department of Health (MDH) or MDH’s Quit Partner media contractor whose work reasonably requires access to the data;


• As required by a Court Order;


• To any person or entity you authorize to receive the data;


• To any other person authorized by state or federal law to receive the data.