Media Release Authorization Form
Please fill out this form to authorize the use of your image and/or voice in media.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
I hereby grant permission to use my image, voice, and/or likeness in any media related to the organization.
Yes
No
Additional Comments or Restrictions
Signature
Date of Authorization
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: