Video Consent and Release Form - MicroEnterprise Social Entrepreneurship

Consent*

Without expectation of compensation or other payment, now or in the future, I hereby give my consent to Micro Enterprise Social Entrepreneurship (MESE or MESENOW) its affiliates and agents to use my image and likeness and/or any interview statement from me in its publication, advertising, or other media activities (including social media)*

This consent includes, but it is not limited to: (Please initial where applicable)

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

(C) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s), or reproduction(s) of me, and/or recording of my voice, in part or whole, in its publications, in newspapers, magazines, and other print media, on television, radio, and electronic and social media, in mailings, for educational and awareness.

Name

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Email

Signature*

Date*