Conversations to Remember – Media/Social Media Consent Form

(Includes, but not limited to: news media, promotional materials, written articles, research, and/or photographs)

I hereby authorize Conversations To Remember, a NJ Nonprofit (hereafter C2R), to use my photo and/or information related to my experiences with C2R. I understand that this information may be used in social media, website, publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, outreach to the public and/or other media. My consent is freely given to C2R, without expecting payment or any other compensation. I hereby release C2R, and its respective employees, officers, and agents from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, video and/or photographs. I understand that I am authorizing C2R to use my first name with last name initial, city/state of residence, and the name of my school with city/state along with my likeness. No other personal information will be released by C2R in accordance with this agreement, unless I subsequently provide separate consent. I understand that I can revoke this release any time in writing to the address listed below, and that the future use of any of my photos or other information authorized by this release will immediately cease. I will send any revocation to: Conversations to Remember, 81 Windsor Drive, Pine Brook, NJ 07058.

Acknowledgement

By checking the box and entering your name below, you acknowledge that you have read, understood, and agree to the terms of this Media/Social Media Consent Form.