Participant Consent & Release Form printable pdf download

Participant Consent & Release Form

PARTICIPANT CONSENT & RELEASE FORM

FOR ALL PARTICIPANTS:

I, ______________________________, in connection with a U.S. Department of

State-sponsored educational exchange program, hereby authorize the Department

and its program implementing partners to photograph, film, or otherwise record

and use my image and/or voice in connection with related public information

programs and activities.

Additionally, I hereby authorize the Department and its implementing partners to

release, publish, or quote such material, including my name, in connection with

related public information programs and activities.

With respect to this material, I understand that content may be included in future

speeches, on the Internet, and through multiple broadcast channels and print media

(which may include use by U.S. Embassies abroad to promote Department

exchange programs and public diplomacy efforts*) but that such content will not

be used for commercial purposes.

I understand that I may decline to give my consent (by not signing this Form)

and still continue to participate in all exchange program activities without

being disadvantaged with respect to those activities.

* If applicable: In providing my consent, I ask that my name, image and/or voice

not be used for promotional purposes associated with the U.S. government in the

following specific countries or territories: _______________________________

__________________________________________________________________.

______________________________

Participant’s Signature

Date

______________________________

Printed Name

eMail Address

______________________________

Participant’s Home City & Country

Participant Consent & Release Form