BTE 30 Years Photo Collection Form

I agree to allow FHI 360 and/or its partners and/or its funders to reproduce, publish and/or otherwise use pictures and/or videos of me and/or my story in print and electronic formats, including, but not limited to publications, videos, exhibitions, advertisements, promotional or educational materials and on websites and social media (e.g., Facebook, YouTube) that help advance public health and/or other development initiatives in connection with FHI 360
activities. I understand that my picture, video or story may be reproduced or published in any medium
without restriction.

I acknowledge that I will not receive payment or any other compensation for the use of my story or photos, and I release FHI 360, its employees and agents from any and all claims which arise out of or are in any way connected with use as described, in any jurisdiction.

If I am under the age of 18, I confirm and acknowledge that my parent/legal guardian has reviewed and agrees to all of the aforementioned consent acknowledgments in this section. Checking this box is the equivalent of their electronic signature.