Media Release Form
I give permission to ICNA RELIEF USA to use my photographs, videos, stories and/or testimonials for educational promotional and/or fund-raising purposes now or in the future in keeping with the general goals of ICNA RELIEF USA.l agree that the above-mentioned photographs, stories and/or testimonials, including transparencies, negatives, prints, digital images, video, movie film, or products thereof may be used by ICNA RELIEF USA, in any legitimate manner for educational promotional and/or fund-raising purposes. I relinquish my rights, title and interest in the photographs, stories and/or testimonials and grant ICNA RELIEF those rights, title and interest.I understand that participation through photographs, interviews, written or video/audio-taped statements or public appearances is not required by ICNA RELIEF USA in order to receive treatment or services. I was not in any way coerced or forced by ICNA RELIEF USA to participate in interviews, photographs or public appearances in order to receive treatment or services.ICNA RELIEF USA respects the privacy and confidentiality of all who receive services, help provide services in the case of our volunteers, and all members of agencies -- governmental or otherwise -- who collaborate with ICNA RELIEF USA or help facilitate our services.I hereby authorize ICNA RELIEF USA to use my photographs, stories and/or testimonials and I discharge ICNA Relief from any liability in the event confidential information is inadvertently disclosed about me.
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Signature of Parent if the person consenting is under the age of 18:
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