FHI 360 Comms Release Form - FHI360

AGREEMENT: PERMISSION TO USE PICTURES, VIDEO AND/OR STORY

Your Name*
First/Given Name Last/Sur Name
Your Email*
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
I have read and understand this consent and release and hereby give FHI 360 consent to use images of me and/or my story.*
- Agree
I have been fully informed of the content of this Agreement in a language I understand and hereby give FHI 360 consent to use images of me and/or my story.*
- Agree
Subject's Signature*

Please use this space to type your full legal name. This line item is the equivalent of your electronic signature.
Date*
MM slash DD slash YYYY

Please select today's date.
If Subject is under age 18, Parent/Legal Guardian's Name

Please use this space to type the full legal name of your parent/legal guardian.
Parent/Legal Guardian's Signature

Please have your parent/legal guardian use this space to type their full legal name. This line is the equivalent of their electronic signature.
Your BTE Site (select one)*
FHI 360 Project and Location