Media Release Form

By completing and submitting this form, I give to Affirmation, its employees, volunteers, and other people officially working on behalf of Affirmation, consent, and permission for an interview and/or photograph(s), still or film, for purposes of publication in newspapers, magazines, or other printed media, or for broadcast by means of video, motion picture, radio, television, or internet transmission. I relieve and agree not to hold Affirmation liable for the interviewing and photographing, and subsequent publication or broadcasting.

I understand that the interviewing and photographs are being carried out with my consent, and I assume responsibility for my consent. 

If the individual involved is a minor, the below must be signed by the supervising adult
responsible for the minor party.