Media Appearance Interview Consent Form
Please complete this form to provide your consent for participation in a media interview and the use of your statements, image, and voice in media materials.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Affiliation or Organization (if any)
Interview Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Interview Location
*
Purpose of Interview / Topic
*
Type of Media for Appearance
*
Video Recording
Audio Recording
Photography
Print/Online Publication
Other
Do you consent to the recording and use of your image, voice, and statements in media related to this interview?
*
Yes, I consent to all uses as described.
No, I do not consent.
If you have any specific restrictions or notes regarding your consent, please describe them here.
By signing below, you confirm that you have read and understood the above information and voluntarily agree to participate in the media interview and grant the necessary permissions.
*
Submit Consent
Submit Consent
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