Media Consent Form

Media Consent Form
I understand that my story, photos and voice are my own and hereby grant my permission to the Anchorage Coalition to End Homelessness (ACEH) and/or its contractors to:
[Check all that apply]*

Interview meTake my pictureRecord my voiceVideotape meOther
I understand the information may be edited and shared both immediately and in the future with audiences of the Anchorage to Coalition to End Homelessness. The possible uses include websites, videos, newsletters, reports, social media, television or radio.

I consent to the following:
[Check one]

It’s fine to show my image including my face.My image is obscured or is cropped so that my identify is not revealed.Other
[Check one]*

My whole name can be used.My first name can be used.Don’t use my real name.
Furthermore, my interview, picture, voice or video can be used by the Anchorage Coalition to End Homelessness:
[Check all that apply]*

For any lawful purpose including Coalition websites, videos, newsletters, reports, social media, television or radio.For internal communications with Coalition staff, board members and partners only.For lawful purposes with these limitations:
My interview, picture, voice or video can be used by the Anchorage Coalition to End Homelessness:
[Check all that apply]*

Up to one month.Up to one year.Indefinitely.Other
I have the right to take back my consent at any time. I understand that participation in any media including for a fundraising event for ACEH is strictly voluntary and my eligibility to receive services is not contingent upon participating in any media or fundraising event. This consent is valid until revoked unless specified above.*
Name*

First NameLast Name
Signature (Anyone under 18 guardian must sign)*

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Optional: Legal guardian name

First NameLast Name
Date*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*Optional: I would like to put the following restrictions on my consent:

I’d like to inspect or approve the finished product that includes my material. (Please make sure we have a way to reach you.)Other, please specify:
Questions? Reach out at communications@aceh.org or 907-312-9547.

For more information about our work, visit aceh.org or find us on Facebook.
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