Waiver Statement

I hereby grant permission to the above-named nonprofit organization and its representatives to record, photograph, and/or interview me and to use any resulting media for organizational, promotional, or educational purposes, in any format, in perpetuity, without compensation.

I understand that my participation is voluntary and that I may withdraw consent at any time by notifying the organization in writing.

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Address

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Participant Signature

Date

If participant is under 18, a parent or legal guardian must also sign below:

Parent/Guardian Name

Parent/Guardian Signature

Date

Nonprofit Media Access Waiver

Waiver Statement

Participant Information