Consent & Authorization Form

Before you register, please agree to this disclosure.

MEDIA CONSENT FORM FOR ADULTS

I,
Name
First Last
, participate in programs and activities with Kidney Donor Match Non-Profit Organization.
I hereby consent to participation in interviews, the use of quotes and the taking of photographs and/or videos of me on behalf of Kidney Donor Match Non-Profit Organization. and its staff. I also grant the right to edit, use, and reuse said products for non- profit, non-commercial purposes, including in print, online, social media and all other forms of media. I consent to the use of my name and association with Kidney Donor Match Non-Profit Organization. for the foregoing purposes:
Signature
Date
Date Format: MM slash DD slash YYYY
Address of Authorizing Individual:

MEDIA CONSENT FORM FOR MINORS

Minor Name:
First Last
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the minor named above by. I also grant to the right to edit, use, and reuse said products for non- profit purposes including use in print, on the internet, and all other forms of media. I also hereby release the Kidney Donor Match Non-Profit Organization and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. I consent to the use of my name and association with Kidney Donor Match Non-Profit Organization for the foregoing purposes:
- News media (online, print and/or broadcast)
- Publications and/or promotional materials
- Closed circuit television programs
- Advertisements
- Websites and social media
- Any other lawful purpose
I give this authorization without expectations of compensation. This consent will remain in effect until I revoke it in writing.
Signature of Parent/Guardian (on behalf of Minor):
Parent/Guardian Name
First Last
Date
Date Format: MM slash DD slash YYYY
Address of Parent/Guardian

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