Anishnaabek Healing Circle

Media Release

Sowing the Seeds of Recovery

Digital Story

The Anishnaabek Healing Circle Access to Recovery Program (ATR) is collecting a series of digital stories about people in recovery from trauma and addictions. The story belongs to the story-teller. You can choose to share your completed digital story, or keep it for your own personal use.

We applaud your courage and generosity for sharing your story: recovery stories offer hope and possibility to those who view them. With your permission, you have our assurance that we will only use the content for educational and informational purposes, not for profit or commercial gain, and with the respect and consideration to which you are entitled.

The Anishnaabek Healing Circle is seeking permission to include your story in the Sowing the Seeds of Recovery digital story series and related educational media such as the SSR Facilitator Manual.Sowing the Seeds of RecoveryDVD Seriesstories may be disseminated to tribal behavioral health and wellness programs, posted on the Anishinaabek Healing Circle website, and shared with local, regional and national audiences with the express purpose of engaging and educating communities about the healing journey of recovery. Sowing the Seeds of Recovery Digital Story-Telling ATR Workshop stories are completed through ATR Service Code 7051 and may or may not be made public, depending on your wishes as the story-teller.

Consent and Permission

I hereby authorize the Anishnaabek Healing Circle and their agents, collaborators and contractors to record and photograph my image for the purposes checked below. I understand and agree that these media images may be edited, duplicated, distributed, reproduced, broadcast and/or reformatted in any form and manner without payment of fees, in perpetuity. (pleaseinitial all that apply)

____ Yes, the Anishnaabek Healing Circle has my permission to use my image, voice, photographs, and all or part of my final digital story to educate people by sharing stories of hope and resiliency.

____ Yes, Photographs/video/ recording taken of me at the workshop may be used for marketing / promotional / educational purposes.

____Yes, my story can be included in the Sowing the Seeds of Recovery digital story series and shared in multiple ways, such as: on the Anishnaabek Healing Circle website; on DVD and in a Facilitator Manual; at presentations, workshops, conferences, community events and nDigiFests.

At no time will any image or recording identify any person as a “client” or “patient” unless the storyteller self-identifies. Images may be explained as community participants in community and/or program activities.Tribal staff may be identified by name, as may be speakers and presenters. Minors will not be identified by name unless express permission is obtained for a specific use.

I understand that my permission for media release is voluntary and in no way affects my or my minor child’s ability to participate in any program or activity. I release the above group from any privacy, defamation or other claims I may have out of use of this story.

______

Name (Adult or Youth) (Please Print Clearly)

Signature______Date______

(Parent or guardian must sign if subject is under age 18)

____ No, my story is mine alone, and at this time I choose not to share it. I understand that I will receive a DVD with my story, for my personal use. The Anishnaabek Healing Circle will maintain a master copy of my digital story but will not use it without my permission. ____ (check if 7051)

______Print Name ______Signature ______Date

Anishnaabek Healing Circle ATR Media Release Sowing Seeds of Recovery Public & Private UsagePage 1

2012 (6-30-15)