Video/Photo Consent and Release Form

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Personalised Support Services, its affiliates, and workers, to use my image 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(place your initials where applicable):

  • 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 conversation, 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 purposes and awareness.

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