Media Policy Acknowledgment Form
Please review and acknowledge the organization’s media policy regarding media capture and usage.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to the Organization
*
Please Select
Employee
Contractor
Volunteer
Event Participant
Visitor
Other
I acknowledge that photos, video, or audio of me may be captured and used by the organization for official purposes.
*
I acknowledge and agree
I do not agree (please specify limitations below)
Please specify any limitations or conditions regarding your media usage consent (if any).
Permission for Media Usage
*
I grant permission for unrestricted use of my image, voice, or likeness in organization media.
I grant permission with the following restrictions (please specify below)
I do not grant permission for media usage
If you selected restrictions, please describe your restrictions here.
Date of Acknowledgment
*
-
Month
-
Day
Year
Date
Signature (please sign to confirm your acknowledgment and agreement to the media policy)
*
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: