Triangle, Inc. Media Consent Form

Permission for Release of Photographs/Video Images - 115 CMR 5.04(2)
INSTRUCTIONS:
1. This form must be completed in full.
2. Ensure that the expiration date or event listed at the bottom of the form is practical.
3. Distribution of copies: original to Triangle, Inc.; copy to individual, guardian, or other legally authorized representative will be emailed upon completion of the form.
SECTION I. Personal Information:
Individual's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Triangle Location*
SECTION II. Permission to Use Images:
- Check the first box to give Triangle, Inc. permission to use one or more photos of you.
- Then, check Box A. if you wish to give Triangle, Inc. ongoing permission to use any images of you.
- Or check Box B. if you only wish to give Triangle, Inc. permission to use one or more specific images of you.
- You may check both A. and B. if you wish to give Triangle, Inc. permission to use both specific images of you and ongoing permission to use any images of you.
Permission to Use Images:*

I am providing my permission for the ongoing use or disclosure of photographs, and images taken of me (or the individual for whom I am guardian) and that Triangle, Inc. does not have to obtain my permission for additional uses of my image(s) and/or information that I have authorized above during the term of this Permission for Release.
Options to Use Images:*

A. I hereby provide my permission to Triangle, Inc. to use any photographic image(s) and/or video(s) of me for the following purposes: on Triangle. Inc.’s digital and printed marketing material to promote Triangle, Inc.B. I hereby provide my permission to Triangle, Inc. to use specific photographic image(s) and/or video(s) of me (email attached image) for the purposes listed below.
Images may be used for the following purposes:
- Posting to the Triangle, Inc. Website and/or Social Media Accounts (e.g. Facebook, Twitter, Instagram, etc.).
  - Note: social media posts may include personal information identifying me by name. By checking this box, you acknowledge that image(s) and/or video(s) posted on the internet can be viewed and downloaded by others and that social media posts may be shared or re-tweeted by other accounts once posted by the Triangle, Inc. and you hereby consent to the same.
- Informational Brochures or Pamphlets
- Photographic or Video Presentations for Public Display
- Photographic or Video Presentations with Personal Information for Public Display
- Other
SECTION III: Written Consent
I understand that I can change my mind and cancel this permission at any time, but that such cancellation is forward-looking only, and will not affect information I already permitted to be released. If I revoke my permission, I must do so in writing and present it to the Triangle, Inc., staff or office authorized to use or disclose my images or information by this Permission for Release. I understand that once the above image(s)/information is/are disclosed, recipient(s) may re-disclose it and the material may not be protected by federal or state privacy laws or regulations. I understand my consent to the use or disclosure of my image(s) or information is voluntary and I do not need to sign this form to continue to receive services from Triangle, Inc.

Questions? Contact Kassi Soulard, Development at ksoulard@triangle-inc.org
Signature of Individual or Guardian*

Clear
Date*

MonthDayYear
Date
Full Name *

First NameLast Name
Identify legal authority if signed by Guardian or other Legally-Authorized Representative*
My consent will expire Date* (date or event - must not exceed one year).
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Email - please enter an email address to receive confirmation that this form was submitted successfully and a copy of this media consent.
example@example.com
Should be Empty:

Permission for Release of Photographs/Video Images - 115 CMR 5.04(2)

SECTION III: Written Consent

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