PSI CHI VIDEO CONSENT FORM
We seek your consent to use your video(s) for the purposes of informing, publicity, or promotional purposes
(e.g., YouTube playlist, social media posts, publications, etc.).
Email completed form to diversity.director@psichi.org
Officer position (if applicable)
Psi Chi chapter name (if applicable)
Link or URL to YouTube Video
Names of additional video authors
(if applicable)
Name(s) or username(s) to be used in
video credit(s)
Additional statements to accompany
video (if applicable)
I obtained written/email permission releases for all persons who appear
on-camera in my video, including minors and their parents/guardians.
I obtained written/email permission to publish the video with any included images or
videos of people, quotes, photos, etc. that I did not originally own.
I hereby grant Psi Chi permission to use my YouTube video (and chapter affiliation if applicable)
along with any requested use of my name, social media post, or statement (e.g., description or comment) as
related to my video. I understand my information may be used for the purposes of editorial, recognition, and
marketing in Psi Chi publications, website, social media channels (including Psi Chi’s YouTube channel and
playlist), print materials, Diversity Advisory Committee campaigns/events, and other Psi Chi communications.
I also understand that I have the right to ask Psi Chi to no longer use my video, information, or statements in
the future.
Note: Personal information requested in this form is stored safely and processed as per the European GDPR guidelines. By
submitting this form, you are giving your consent to use of your data in various publications.
