IDentity X Her · Participant forms

Photo & video permission

We celebrate learning and community through photographs and recordings. Please tell us what you are comfortable with. Permission is optional. Declining will not affect participation.

Print this form, complete it and return it directly to the program facilitator. A parent or legal guardian must sign for participants under 18. Adults may sign for themselves. Nothing entered here is sent to IDentity X Her or saved by this page.

Participant name

Program or event

Participant is under 18Participant is 18 or older

1. Choose permission for each type of media

Permission applies to photographs or recordings made or arranged by IDentity X Her during the program or event named above. Please mark one answer per row. An unanswered item does not grant permission.

PhotographsI give permissionI do not give permission

Video recordingsI give permissionI do not give permission

Audio / recorded voiceI give permissionI do not give permission

2. Where may approved media be used?

Check each use you authorize. Permission is limited to the media types approved above and the uses checked below.

IDentity X Her website and digital newslettersIDentity X Her social media accountsPrinted program materials, community presentations and reports to supporters

Approved uses may describe program activities, celebrate participant work or introduce the organization to the community. Media will not be sold. Full names, contact information and other personal details are not authorized by this form.

Optional: I also permit the participant’s first name to accompany approved media. If unchecked, do not identify the participant by name.

3. Acknowledgment & signature

I understand that online media can be viewed, copied or shared by others. I may change my choices for future use by contacting Jaquanah M. Williams at 315-949-1985. IDentity X Her will stop new uses within its control after receiving the request; previously distributed print materials or copies shared by others may not be recoverable.

I have reviewed the choices above. I am the adult participant or the parent/legal guardian authorized to make these choices for the minor participant.

Printed name of person signing

Relationship to participant (or “self”)

Signature — sign after printing

Date

Use your browser’s print dialog to print a blank or completed form, or choose “Save as PDF.” This is not an online submission or electronic signature.