Add Your Story

Please mail the completed form and a donation of $15 to:
                         Powerful Beyond Measure
                         P.O. Box 112
                         Hull, MA 02045

Your information:

     This information will only be used to verify an actual person submitted the
      story.  We will not sell, rent or give this information to anyone ever. 

      NOTE:  This form must be filled out by the survivor.  If the survivor cannot
      complete the form (i.e. is a minor, has passed away, has mental or physical
      difficulties), please explain the circumstances and your relationship to the
      survivor below:

      ____________________________________________________________________               

     _____________________________________________________________________

     _____________________________________________________________________

          First Name:       _______________________________

          Last Name:       ________________________________

          Address:           _________________________________

                                  _________________________________

                                 __________________________________

          Email Address:   _________________________________

Your Story:

      Please use the space below and/or additional paper to write the story of your abuse.  You
      can write in as much or as little detail as you like.  Remember this story will be read by
      people who know the abuser now, so it may help to write it as though you
      were telling them.

Abuser Information:

      Please complete as much information as possible about the abuser. 

      First Name:   __________________________________

      Last Name:   __________________________________

      Any Nicknames or Aliases:  _______________________________

                                                 _______________________________

                                                 _______________________________

      Last Known Address:   ____________________________________

                                          _____________________________________

                                         ______________________________________

      Approximate month and year at last know address:  __________________________

      Date of Birth or Approximate Age:   ______________________________________

     Any other information that could help us identify or find him (i.e. Social
     Security Number, other addresses, jobs worked, marital status, etc...)
      

By signing below, you are asserting that the above information is true and accurate to the best
of your knowledge and belief.

Signature:  __________________________________________________