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2. First Name*
3. Last Name*
5. Zip Code*
6. Age
8. Email*

   Required so that we can contact you with any questions. San Leandro History Museum will not share your contact information. If you are also submitting a file please be sure to use the same email so we can match your submissions.

10. How has the COVID-19 pandemic specifically affected you, your family or your community?
12. Have you experienced a significant life event since this began? A birthday, anniversary, birth, death, graduation, wedding, etc.? Tell us about how being in quarantine affected your experience.
14. How do you think life will or will not be the same after we emerge from sheltering in place?
16. Is there anything you'd like to add about your experience with the COVID-19 pandemic?
18. Informed Consent & Copyright Permission Form

    I hereby certify that I am at least eighteen years of age (if under the age of eighteen, form must be completed by parent) and I voluntarily agree to share my interviews, images, and/or personal materials with the San Leandro History Museum, administered by the San Leandro Public Library, to document life during the novel coronavirus pandemic in San Leandro, California.

    1. Yes, I agree
20. By submitting my story and its associated elements (the "Story") to the San Leandro History Museum, I acknowledge and agree that the San Leandro History Museum may, in its sole discretion, use the Story as part of a collection of stories (the "Collection"). I hereby grant to the San Leandro History Museum a non-exclusive, worldwide, irrevocable, perpetual, sublicensable, and royalty-free license to use, reproduce, publish, publicly display, excerpt, abridge from, and distribute, in whole or in part, the Story, including my name in association with the Story, in any manner or form, and in any and all media now known or hereafter developed, in connection with or furtherance of the Collection. I waive all common law and statutory rights of publicity and privacy, moral rights, and any other rights that I may have with respect to the Story. I also acknowledge and agree that I shall have no ownership rights in the Collection and that I will receive no compensation for the use of my Story. I also understand that the material I share may not be included in the archive if it is deemed out of scope by Museum staff.

    I represent and warrant that my Story, to the best of my knowledge, does not and will not infringe the rights of any third party.

    1. Yes, I agree
22. I agree that my submission may be shared in whole or in part on Facebook and Instagram and online on the San Leandro History Museum website. Any submissions shared on social media will not contain any personal information. If you wish to contribute a submission, but do not want it shared on Facebook, Instagram or the San Leandro History Museum digital collection click no. You will still be able to submit your story and it will be archived in the Museum.

    1. Yes, my submission may be used on the Museum's social media.
    2. No, do not use my submission on the Museum's social media.
24. Further Information

    For questions contact the program coordinators via email.

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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

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