Name

First Name

Last Name

Public or Anonymous? *

DO NOT USE my name on air. Please keep me anonymous.

YES, YOU CAN USE my name on air if/when sharing this song and story.

Granting Authorization for Use of Submitted Info *

By checking below, I authorize Kate Sattler and CAMP Radio: to use, edit for clarity or length, broadcast, publish, and distribute my name (unless anonymity is selected), text submission and/or voice recording, and other info provided on this form as part of and in promotion for Songs that Shaped Me without prior review. (1/24)

I authorize the use of the info according to the terms above.