Journalist Interview Media Consent Form
Please complete this form to share interview details, media preferences, and your permission for recording, quoting, photography/video, and publication.
Interviewee Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Pronouns / Title
Organization / Affiliation
*
Role / Job Title
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City and Country / Location
*
Interview Details
Interview topic or subject
*
Journalist, publication, or media outlet
*
Interview date and time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Interview format
*
In person
Phone
Video call
Email
Other
Location or platform details
Intended publication date or timeframe
Media Use Preferences
Preferred interview method
*
Recorded audio
Recorded video
Live notes only
Email Q&A
Other
Can you be quoted by name?
*
Yes
Yes, but I want to review direct quotes
No—anonymous only
Anonymity or pseudonym preference
Topics or sensitive areas to avoid
Would you like to review quotes for accuracy before publication?
*
Yes
No
Recording and Publication Consent
Signature
*
Follow-up and Release Details
Preferred Follow-up Contact Method
*
Email
Phone
Either
Best Time to Contact
Hour Minutes
AM
PM
AM/PM Option
Permission to Contact for Fact-Checking or Follow-up Questions
*
Yes
No
Additional Notes or Restrictions
Submit
Submit
Should be Empty: