Governor's Committee
on Disability Issues
and Employment
Publication, video and website
consent and release agreement
The committee
seeks
permission to
use your photo,
name, voice,
statement,
written work
and/or art
Release
agreement
Please sign here
Please complete
this section for
minors
Governor's Committee on Disability Issues and Employment (GCDE) employees and
members of the public are occasionally asked to be a part of GCDE’s publicity,
publications, and/or public relations activities, which may include representation in the media.
This signed form indicates agreement that the subject’s name, picture, art, written work,
voice, verbal statements and/or portraits (video or still) may appear in the committee’s
publications, videos and/or website, or in print, social or broadcast media. These images may
or may not personally identify the subject. The subject also agrees that:
No money shall be paid.
Consent and release have been given willingly.
The name, picture, art, written work, voice, verbal statements, portraits (video or still) may
be used in the future.
Governor's Committee on Disability Issues and Employment, agrees that the subject’s
name, picture, art, written work, voice, verbal statements and/or portraits (video or still)
shall be used only for public relations, public information, event or project promotion,
publicity and instruction.
If the subject or, in the case of a minor child, parent or guardian wish to rescind this
agreement, he or she may do so at any time with written notice.
Agreement
I authorize the Governor's Committee on Disability Issues and Employment to use my name,
voice, verbal statements, and/or any photographs, film, digital recording or videotape that may
contain my likeness, for publicity or informational purposes. This includes the editing,
duplication, reproduction, copyright, representation in the media, exhibition, broadcast,
posting on GCDE’s website, and/or other non-profit use and distribution of such
photographs for purposes deemed suitable by GCDE, unless I make my wishes to the contrary
known. I understand that my image or information that I provide may be used without my
review.
Subject (print name) Signature of
subject Date Phone number
If subject is a minor child (less than 18 years old), complete the following section.
Guardian (print name) Signature of guardian
Minor (print name) Date Phone
Please give this form to Emily Heike or GCDE Staff.
click to sign
signature
click to edit
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click to sign
signature
click to edit
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