Consent, Confidentiality, & Liability Form
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Full Name  (serves as e-signature) *
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CONSENT FORM. Photo/Video Release: AUTHORIZATION TO USE PHOTOGRAPHS AND/OR AUDIO-VISUAL. I hereby authorize From Prison Cells to PhD, Inc. to use, reproduce, and/or publish photographs and/or video that may pertain to me— including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on the organization’s Internet Web Page. This authorization is continuous (unless otherwise stated in print or electronically) and may only be withdrawn by my specific rescission of this authorization. Consequently, the nonprofit may publish materials, use my name, photograph, and/or make reference to me in any manner that the Corporation deems appropriate in order to promote/publicize service opportunities. *
Confidentiality Statement: As a general policy of privacy related to all information shared in the program and organization, there is an expectation of confidentiality. This means that all personal information that is shared by others in small and large group interactions, in papers, discussion boards, in presentations, etc. is not to be shared outside of the online and/or face-to-face interactions in any way without the permission of the person, the program, or organization. Violation of this policy may result in being dropped from the program and possibly further administrative action being taken. Do you accept this statement of confidentiality? *
(P2P Scholars Only) CONSENT TO RELEASE STUDENT INFORMATION: I authorize the release of my student records to P2P and I authorize P2P educational related documents on my behalf.
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Release of Liability: I understand my expected involvement in the P2P Program and I voluntarily enter into this release and waiver of liability. *
A copy of your responses will be emailed to the address you provided.
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