Media Consent and Release Form

I give my consent to The Diocese of Hereford, its affiliates and agents, to use my image and likeness and/or any interview statements from me in all media known now or in the future. This consent includes, but is not limited to:

1. Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
2. Permission to use my name; and
3. 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 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.

I confirm that I have read the information above and understand that I am able to withdraw my consent at any time, and will contact the Diocese of Hereford Communications Team to notify them of my withdrawal.

If you are signing on behalf of the person (if subject is under 18 / as a legal guardian / carer / family member / responsible person) Please enter your own details in the Guarantor section.

Name of Person:*
Location:*
Purpose of Recording:*
Type of Recording:*	Audio Film Photography
Email Address:*
Full Name of Guarantor (on behalf of person):
Please enter the verification number:*
* Required Fields