First Name

Last Name

Your Email

Cell Phone

Street

Apartment #

City

State

Zip Code

Job Title

Consent for The Fedcap Group to Use My Story and Image (photo/video): I hereby authorize The Fedcap Group, its designees, licensees, and assignees, to: Record by writing, audio, and/ or video my remarks, and to reprint, transcribe, edit, an excerpt from, or otherwise any and all material from my presentation in The Fedcap Group publications; on its web site (s) or social media platforms.Use the photo/s and/ or video/film footage taken of me, or in which I may be included with others. Use my name and the personal information that I have shared during said remarks or footage. And use, reuse, publish, and republish in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, specifically including illustration, promotion, art, editorial, advertising, and trade, without restriction as to alteration. I hereby acknowledge The Fedcap Group as copyright proprietor off all rights to such transcripts or summaries of my presentation. Nothing herein prevents me from using this same material elsewhere in any way I choose. Such use may include promotional displays, newsletters, brochures, annual reports, display advertising, direct mail fundraising appeals, or internet use by The Fedcap Group and its designees. In addition, I give up the right to inspect or approve the finished product, including written or electronic copy, where my likeness appears. Additionally, I give up any right to payment or other compensation arising or related to the use of the photo and or video/film footage. I am 18 years of age and I fully understand the contents, meaning, and impact of this release.

By checking here, I agree to the above statements.

Name

Date

Δ