Consent & Release Form
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the Portage County Safety Council, its producer, its affiliates and agents, to use my image, likeness, audio & video recordings, and/or any interview statements from me in its podcasts, videos, publications, advertising or 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, title, and company 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 podcasts, videos, publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.


This consent is given in perpetuity, and does not require prior approval by me.
Name *
Title *
Company *
Email *
I have read the podcast consent & release terms noted above and hereby agree to all terms. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy