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Please complete all pertinent authorization sections.
As part of the [full name of program; for example, Fort ABC Worksite Wellness Program] sponsored by the [full name of sponsoring agency], [day month, year] in [city, state or APO], my signature in any or all of the numbered sections below indicates my agreement to and the granting of permission for the indicated activity.
- VIDEOTAPE
I, (PRINTED NAME) _________________________________________ grant the [full name of sponsoring agency] permission to videotape part or all of my presentation and I allow this videotape to be utilized by the [full name of sponsoring agency] for educational and promotional purposes.
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Signature |
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Date |
- PHOTOGRAPH
I, (PRINTED NAME) _________________________________________ grant the [full name of sponsoring agency] permission to photograph me and I allow this photograph to be utilized by the [full name of sponsoring agency] for educational and promotional purposes.
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Signature | |
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Date |
- INTERVIEW
I, (PRINTED NAME) _________________________________________ grant the [full name of sponsoring agency] permission to interview me related to my conference presentation and I allow this information to be utilized by the [full name of sponsoring agency] for educational and promotional purposes.
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Date |
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