Media Release Form - Asbury Institutes

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Asbury Theological Seminary, its affiliates and agents, to use my image, video footage, Voices story, and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:

Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
Permission to use my name; and
Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

Name*

This consent is given in perpetuity, and does not require prior approval by me.

First Last

Minor (under 18)*

Is the aforementioned consignee a minor?

No
Yes

Signature*

Type in your full name

Name of parent or legal guardian

First Last

Parent or legal guardian signature*

The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

By submitting this form, I am giving Asbury Theological Seminary permission to use my name, picture, photograph, portrait, visual likeness, video or voice in the media outlets listed above.