• I agree to allow FHI 360 and/or its partners Subject’s Name (print) 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
  • Please use this space to type your full legal name. This line item is the equivalent of your electronic signature.
  • MM slash DD slash YYYY
    Please select today's date.
  • Please use this space to type the full legal name of your parent/legal guardian.
  • Please have your parent/legal guardian use this space to type their full legal name. This line is the equivalent of their electronic signature.
  • FHI 360 Project and Location