Digital Likeness Consent Form
Please complete this form to provide or withhold permission for the capture, use, editing, and publication of your digital likeness (photo, video, voice, or other recognizable likeness).
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Representative Requesting Consent
*
Type(s) of Digital Likeness Covered
*
Photo
Video
Voice Recording
Other Recognizable Likeness
Intended Use(s) for Digital Likeness
*
Marketing Materials
Website/Social Media
Educational Content
Internal Communications
Other
Duration of Consent
*
Indefinite (no expiration)
Specific End Date
Until I revoke consent in writing
If you selected 'Specific End Date', please specify:
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How can you revoke your consent?
*
By written request to the organization
By email to the organization
Other
Submit Consent
Should be Empty: