Centennial Celebration Media Release Form

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Asbury Theological Seminary, its affiliates and agents, to use my image, recording, audio interview/quotes/clips, and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:

Recording usage

Yes, you can use my audio recording.
No, you cannot use my audio recording.

Your consent includes all outlets listed below, but is not limited to these only.

Seminary publications/videos
Seminary website
Seminary social media initiatives
Seminary Promotion/Advertising
Seminary Events
Local/national/regional news media (with the permission of Asbury Seminary)

Name*

This consent is given in perpetuity, and does not require prior approval by me.

First Last

Minor (under 18)*

Is the aforementioned consignee a minor?

No
Yes

Signature*

Type in your full name

Name of parent or legal guardian

First Last

Parent or legal guardian signature*

The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

By submitting this form, I am giving Asbury Theological Seminary permission to use my name, picture, photograph, portrait, visual likeness, video or voice in the media outlets listed above.

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