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Photo and Video Consent and Release Form
Without compensation or other remuneration, now or in the future, I hereby give my consent to Council of Asian Pacific Americans, its affiliates and agents (collectively, “CAPA”), to use my image and likeness and/or any interview statements from me in its publications, advertising or any other media activities (including the Internet). This consent includes, but is not limited to:

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in publicity materials or mailings and/or in workshops, presentations or curriculum for educational awareness.

I hereby release CAPA from any liability arising out of its use of my image, likeness, or interview statements.

This consent is given in perpetuity, and any use of my image, likeness, or interview statements does not require any further approval by me.

Name *
Email *
Address *
Phone number *
Signature *
Date *
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The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.
Signature of Parent or Legal Guardian
Print Name
The following is required if the consent form has to be read to the parent/legal guardian:I certify that I have read this consent form in full to the parent/legal guardian whose signature appears above.
Date
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Signature of Organizational Representative or Community Leader
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