Name *

First Name

Last Name

Address *

The address you'd like me to mail your Polaroid to

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I give Jennifer Stamps permission to post the finished Polaroid in her portfolio and/or on Instagram *

Yes

No

I agree to post a photo of the finished product on Instagram and tag @jenbroideroid *

Yes

No