Community Beyond Violence Media Release Form - Crisis Intervention Training
In our outreach and prevention efforts, we periodically use photos and videos captured at training and/or community events. This is an important way to engage our community in our various publications. However, we take your privacy and confidentiality seriously. Please read the below release and consider mindfully consenting to this release to assist our efforts. All information provided will be kept confidential. 
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Email *
Date *
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First Name *
Last Name *
Street Address *
City, State, Zip *
Phone Number *
If consented to, this release will hereby grant permission to Community Beyond Violence and/or Nevada County Community Action Team to use personal statements, photographs and/or video of you (or a minor in your care if applicable) in publications, news releases, online and in other communications related to their missions.
My consent is freely given as a public service, without expecting payment.
I release Community Beyond Violence and their employees, officers and board members from liability which may arise from the use of such information.
I understand that I can revoke this release any time in writing and that the use of my photo/video or other information authorized by this release will immediately cease.
Do you consent to this release? By clicking Yes below I certify that I have read the release and agree with this release. *
Let us know how you prefer your name to be presented (if applicable): *
I want to keep up on what is happening at Community Beyond Violence. Please add me to your monthly e-newsletter list! *
A copy of your responses will be emailed to the address you provided.
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