PUBLICITY RELEASE FORM | Disability Rights California

This media release form gives permission to Disability Rights California to use an individual's name, image, and story in various forms of media, including but not limited to, newsletters, website stories, social media, and other materials for the purpose of promoting the organization's mission and raising awareness about disability rights issues. The individual signing the form is giving consent for their personal information to be used in these ways. Disability Rights California will not sell or use this material for commercial purposes.

Name

What is the name of the Person/Parent/Guardian/Conservator signing this release form?

Granting Consent

By checking this box you agree to give permission to Disability Rights California (DRC) to use information about/of you, or about/of your Child/Conservatee, for whom you are the Parent/Guardian/Conservator for.

Child/Conservatee Name

What is the name of the child/conservatee signing this release form?

Please check the box or boxes below you agree to allow Disability Rights California to use and/or share:

Your Name and/or the Name of Your Child

Yes

Information About Help Disability Rights California Gave to Me and/or My Child

Yes

Photograph of Myself and/or My Child/Conservatee

Yes

Poems, Artwork, and/or Reflections

Yes

Date

Signature (Full Legal Name)

Please print the full Legal Name of the Person/Parent/Guardian/Conservator signing this form.