Consent FormModule 2: Create a plan | sample material |”Consent form”

The following template is based on Families USA’s consent form. If your organization chooses to use this form in your story collection efforts, we recommend that you check with a lawyer or counsel. This will help to ensure that your consent form offers your organization sufficient protection for how you intend to highlight stories or share contact information. Insert your organization’s name where noted.

I, ______, agree to be interviewed, filmed, audiotaped, and/or have my pictures taken. I agree that any interview information, video, audio, or photograph (“materials”) can be used in publications, presentations, websites, advertising, or other media. I understand that these Materials are to advance [INSERT ORGANIZATION][INSERT ORGANIZATION]’s goals, including public education and work with the news media.

I understand that [INSERT ORGANIZATION] [INSERT ORGANIZATION] may contact me for an interview with a thirdparty (including another organization or member of the media), or for sharing my story at an event. If that happens, [INSERT ORGANIZATION] [INSERT ORGANIZATION] will contact me before each opportunity, and I understand that I am not obligated to participate in any opportunity.

Unless I say otherwise, I understand and agree that [INSERT ORGANIZATION] [INSERT ORGANIZATION] may edit, use, publish, distribute, and republish any materials for work with the media or on public education efforts. I understand that I have no rights in the materials. I waive all right to inspect or approve the uses of materials, now or in the future.

I understand that I will not be compensated for participating in sharing my story or for the use of the materials.

I release [INSERT ORGANIZATION] [INSERT ORGANIZATION] and its agents, employees, and contractors from all claims, demands, and liabilities in connection with the above.

My signature below means that:

  • I have read and understand this consent form.
  • I have been given all of the information I asked for regarding sharing my story.
  • All of my questions were answered.

I agree to everything explained above.

Printed name of the subject:______

Signature: ______

Street: ______City: ______State: Zip:

Phone number: ______Date:

IF THE SUBJECT IS UNABLE TO CONSENT FOR HIMSELF OR HERSELF(as identified above)

Legally responsible person:______

Relationship to subject:______

Signature:______

Street: ______City: ______State:____ Zip:______

Street: ______City: ______State: Zip:

Phone number: ______Date:______Phone number: Date:[CB1]

[CB1]Note to Evan: This should be fill-able (lines after colons)