I grant permission to Salem City Heart & Soul and those working on their behalf to record my name, likeness, image, voice, and the content of my story on film, digitally, or in print for their use to educate about and promote understanding of the Salem City Heart & Soul project. I agree that the recorded material may be edited and used in whole or in part for any and all broadcast, cable, web, print format, and/or exhibition purposes. I agree that the program may be duplicated on any media and sold or distributed, and that it may be used for audio/visual, multimedia, online, video, and for all other media, in perpetuity.

I understand that I have no rights to the program, or any benefits derived from it or its distribution, and that I shall not receive any compensation for my participation. I confirm that any and all material furnished by me for this program is either my own or otherwise authorized for such use without obligation to me or any third party.

I also consent to the use of my name, likeness, voice, and biographical material about me for program publicity, organizational promotional purposes, as well as for packaging of the program for distribution, or promotion of the program.

I expressly release Salem City Heart & Soul from any and all claims arising out of the use of this material.

I represent that I am the parent and/or guardian of the minor who has signed the above or is a participant in the program. I agree that we both shall be bound by this agreement.

Please check the box that applies to you for each of the demographic sections below. This is anonymous so we can be sure we are hearing from everyone.