AUTHORIZATION for PHOTOGRAPHY, VIDEO, AUDIO, TESTIMONIAL, AND PUBLIC RELEASE
Project1.27 produces materials for educational and fundraising purposes, some of which relate to the clients the Neighbor Program serves. These materials may be distributed to the general public, donors, or the media.
The signing of this release form is strictly voluntary and will not affect the student’s participation in any clinical or school classroom.
At the Neighbor Program we use your experiences to help us recruit excellent people for our families and welcome new families to our mission. We ask that anyone who participates in the Neighbor Program sign a release to allow us to use your stories.
Please review the following for options and select which option you would like in the drop-down question below. Then sign your name. Please note: We will confirm with you again verbally or in writing before taking any recordings/photos of you. For example, if you agree to join us on a podcast interview or news piece.
Option 1 I give permission for photographs, testimonials, audio, and/or video to be taken of me/my family/group's experience as a Neighbor. I understand that these materials may be used by Project1.27 for educational and fundraising purposes, including distribution to the general public, donors, or the media.
Option 2 I give permission for photographs, testimonials, audio, and/or video to be taken of me/my family/group's participation as a Neighbor but the client must be de-identified before public use. *Deidentified means that my face will be blurred or obstructed, my name changed or withheld, or details changed to protect my identity. I understand that these materials may be used by Project1.27 for educational and fundraising purposes, including distribution to the general public, donors, or the media.
Option 3 I give permission for photographs, testimonials, audio and/or video to be taken of me/my family/group's experience as a Neighbor. I understand that this selection will limit the use of these materials solely for distribution inside of Project1.27.
Option 4 I do not give my consent for the taking of any photographs, testimonials, audio and/or video of me/my family/my group participating as a Neighbor.
This release may be revoked by notifying Project1.27 in writing to the client’s primary therapist or the Neighbor Program staff. Any revocation will not affect materials produced or distributed prior to receipt of the written revocation of consent.
