Media & Press Interview Consent Form
Interviewee Information
Full Name:
Organization/Title:
Contact Email:
Phone Number:
Date:
Media Outlet / Interviewer Information
Media Outlet:
Interviewer Name:
Consent
I consent to having my interview recorded (audio, video, photograph, or written) by the above Media Outlet / Interviewer.
I authorize the use of my name, likeness, and statements for publication, broadcast, and/or distribution in media and press materials.
I understand that I will not receive compensation for participation or for use of any interview materials.
Additional Notes or Restrictions:
Interviewee Signature:
Date:
Interviewer Signature:
Date: