Photo/interview/document Release Form

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PHOTO/INTERVIEW/DOCUMENT RELEASE FORM
I hereby give permission to:
Name _______________________________________________________________________
Address _____________________________________________________________________
Phone __________________________ E-Mail ______________________________________
1) to interview me / photograph me (still or moving images) / record my voice, (circle one, two,
or all three items to indicate permission)
2) and to use, reuse, publish and republish the same in whole or in part on the World Wide Web
for her/his class English 101: Exploring Litercies at Emory University
3) and to use a pseudonym / my first name / my full name in connection therewith. (circle the
one for which you give permission)
4) and to use, reuse, publish and republish photos of artifacts or artifacts themselves (e.g.,
documents) in whole or in part on the World Wide Web for her/his class English 101: Exploring
Litercies at Emory University
I will make no monetary or other claim, including any and all claims for libel, for the use of the
interview and/or the photograph(s)/video/recording of my voice or the use of photos or other
artifacts provided during the interview.
This authorization and release also applies to the organization(s) / publication(s) for which the
photographer/interviewer took the photos/video, recorded my voice and/or conducted the
interview, and to their legal representatives, licensees and assignees.
Note exceptions here and/or by crossing out points above to which the photo/interview
subject does not agree. Subject reserves the right to decline to answer certain questions and
to stop the interview if he/she becomes uncomfortable. He/she may refuse the use of his/her
full name and/or of his/her address, and may refuse to have his/her full face photographed.
Name of Person(s) to be Interviewed/Photographed:
Print Name: __________________________________________________________________
Signature (if interview/photo subject is under age 18, an adult must sign):
____________________________________________________________________________
Relation of Signer to Subject (if subject is under age 18): _______________________________
Date: _______________________________________________________________________
Witness:
Print Name: __________________________________________________________________
Signature: ___________________________________________________________________
Date: _______________________________________________________________________

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