Media Release | exceedpdx

Media Release Form

First name

Last name

I understand that my story, photo and voice is my own and hereby grant my permission to Exceed Enterprises to:

[ CHECK ALL THAT APPLY ]

Interview me

Take pictures of my image

Videotape me

Record my voice

I understand that the information I provide may be edited and shared both immediately and in the future with organization’s audiences on websites, in videos, and on other public online forums (email, social networking sites, newsletters, etc.).

I understand that media shared on the internet is subject to sharing and is accessible globally. I have the right to modify or retract my consent after the production of the video, written story, social media feature, etc.

I consent under the condition that the following requirements are met:

Your Signature

Select a date

Guardian Witness

Select a date