Media Interview Consent and Agreement Form

I hereby consent to be interviewed and/or recorded (audio, video, or written) by representatives of

for the purpose of media coverage, publicity, educational, or promotional use.

Participant Information

Full Name

Address

Phone

I authorize the use of my interview, likeness, image, voice, and/or statements for the intended purposes.

I understand the material may be published or broadcast in various media formats.

I understand that I will not receive compensation for such use.

Additional Comments or Limitations (if any)

Participant Signature

Date

Interviewer/Organization Representative

Date