Media Disclosure Consent Form

Please complete this form to provide your consent for media usage and disclosure.

First name

Last name

Email address

Phone number

Date of birth

Are you 18 years of age or older?

Yes

No

Media Consent and Release

Please read carefully and indicate your consent for the following media usage:

I consent to the following uses of my image, voice, and likeness

Photography for promotional materials

Video recordings for marketing purposes

Audio recordings for testimonials

Use in social media content

Use in websites and digital platforms

Use in print materials and brochures

Duration of consent

1 year

2 years

5 years

Indefinite (until revoked)

How long should this consent remain valid?

I understand that I have the right to revoke this consent at any time by providing written notice

I acknowledge that no compensation will be provided for the use of my image, voice, or likeness

I confirm that I have read and understood all terms of this media disclosure consent form

Additional comments or restrictions

Digital signature

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Please provide your digital signature to confirm your consent

Date of signature

Month

Day

Year