BTC Media/Photo/Video Release Form

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The BTC will always let you know when we're recording, filming, and/or taking pictures, and we will honor any request to remove pictures and/or names from any posting of your image.

I,_____________, grant permission to the Basement Teen Center to use my authorized image, voice recordings, artwork, and/or any interview statements, from me for the purpose of publication, promotion, illustration, advertising, media activities, annual reports, outreach campaigns, fundraising campaigns, etc.

*

[Enter your legal name.]

This consent includes the specific permissions below. *

(Check all that apply)

Photographs of me

Video images of me

Images that I've produced (such as paintings or photographs).

My audio statements taken during interviews

My written statements or stories taken during interviews or activities

Required

I authorize the permissions selected above to be used: *

With my name

Without my name. Please keep my identity anonymous.

The BTC will not print or publish your full name. If you give permission to use your name, please enter below EXACTLY as you'd like your name to appear in print. (This can be a legal name, a nickname, a middle name, etc.: the name you are comfortable with us printing.)

I understand that I will NOT be compensated for my participation. *

I agree.

l acknowledge that: *

I am over 18 years of age

I am under 18 years of age (Parent/Guardian Electronic Signature Required)

If under 18, I understand that the BTC will contact a parent/guardian for legal permission permission.

I understand!

Clear selection

My electronic signature: I acknowledge that my electronic signature grants permissions that I have selected above. *

Please type your full name.

Your email: *

Your phone number:

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This form was created inside of Washington County Youth Service Bureau. Report Abuse

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