Media Release Form
For questions about this form, contact Anna Elgart, Communications Manager, California Quality Collaborative/Purchaser Business Group on Health, at aelgart@pbgh.org.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Title
*
Organization/Company
*
Email
*
example@example.com
Can your pronouns be published along with your name? If yes, please type them in below in the following format: she/her/hers
I give the California Quality Collaborative/Purchaser Business Group on Health permission to use the following media types for communications purposes:
*
photography
video
testimonial
I give the California Quality Collaborative/Purchaser Business Group on Health permission to publish the above media on the following communications channels:
*
website (calquality.org)
social media (LinkedIn)
email/newsletters
publications
other materials, as needed
What is the name of the person at the California Quality Collaborative who requested you complete this form?
Signature
Please verify that you are human
*
Submit
Should be Empty: