Broadcasting Texas Video Veteran Project: Video Consent and Release Form

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Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Broadcasting Texas, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet).

Email *

This consent includes, but is not limited to: (Please check all items)

Agree

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

Agree

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

This consent is given in perpetuity, and does not require prior approval by me.

Full Name
*

Military Branch *

Rank *

Years Served (from entry to exit) *

Locations Served *

Phone Number *

Would any member(s) of your family be willing to participate?

Yes

Maybe

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