Consent & Confidentiality Form
Must be filled out for each additional person in the video.
Full Name (serves as e-signature)
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 This authorization is continuous and may only be withdrawn by my specific rescission of this authorization.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, 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 or the program. Violation of this policy may result in being dropped from the program and possibly further administrative action being taken. Do accept this statement of confidentiality?
A copy of your responses will be emailed to the address you provided.
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