Publication/website/photo / Video / Interview Consent

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PUBLICATION/WEBSITE/PHOTO / VIDEO / INTERVIEW
CONSENT FORM
I, _____________________________________________ (name) residing at
_______________________________________________________ understand that the Community
Service Society promotes its work among the public through publications, website, the media, and
appeals for support. By signing below, I grant permission to the Community Service Society to include
and identify me in any publications, photographs or other online and visual recordings it may use for
educational, publicity, and / or fundraising purposes. If I was interviewed by CSS staff, I also give
permission to CSS to use my name and any of my direct quotes for publicity and / or fund raising
purposes in any medium. I understand that CSS will own all rights to the photographs, moving images,
sound recordings, and other media, and that I will not be compensated for any use.
_____(initial) By initialing here, I also grant permission to Community Health Advocates (CHA) to
include and identify me in publications, photographs, or other online and visual recordings it may use for
educational, publicity, and/or fundraising purposes.
_____(initial) By initialing here, I also grant permission to the Health Care For All New York
(HCFANY) coalition—of which CSS is member—to include and identify me in publications,
photographs, or other online and visual recordings it may use for educational, publicity, and/or
fundraising purposes.
__________________________________________
__________________
Signature
Date
If person is a minor, signature of parent or guardian is required instead, and indicates that the parent /
guardian consents:
__________________________________________
__________________
Signature of Parent / Guardian
Date
Print Name: _________________________________
Updated 1/20/2011

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