Brand Partnership Media Consent Form
Please complete this form to provide your consent for the use of your media in connection with our brand partnership.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Brand/Organization Name
*
Type of Media Covered by Consent
*
Photographs
Video Footage
Audio Recordings
Written Testimonials
Other
Duration of Consent (if applicable)
Please Select
Indefinite
1 year
2 years
Other (please specify below)
Please specify any restrictions or special instructions regarding your consent (optional)
Signature (please sign below to confirm your consent)
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: