2025 Depots/Milk Express Sites Media Participant Release Form

The undersigned hereby transfers and grants to The Milk Bank and all related partners including milk depots and milk express sites the exclusive right to all or any part of my (his/her) interview/photograph/video or film likeness, regardless of the medium by which it is recorded. I understand that my image, quotations, name, story, testimonial and other information may be utilized for educational, promotional, or similar purposes. The undersigned also hereby transfers and grants to The Milk Bank the exclusive right to use and authorize others to use all or any part of my (his/her) interview/photograph/video in related media such as books, magazines, journals, pamphlets, electronic (Internet) and other formats.

The undersigned also hereby releases The Milk Bank and its directors, its members, trustees, officers, employees and agents from any and all claims, demands, causes of action and suits, including but not limited to, claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of this interview, photograph or video.

I understand that I may withdraw my consent at any time and that this consent must be provided in writing. Withdraw of consent does not modify the previous use of any medium in any manner, but will prevent TMB from utilizing my name, information, and any other media in the future.

Name*

First NameLast Name

Which milk depot or milk express site did you visit? Please note organization or city

Signature*

Date*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

If a participant is under 18 years of age, this form must also be signed by a parent or guardian.

Signature

Date

I may also choose to opt out of specific channels or situations (i.e. news media interviews). Please describe any situations not covered by this release.

By clicking the "Agree" button below the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.