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Consent & Authorization Form
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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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