Media Release Form (Page 2 of 4) in pdf

Media Release Form Page 2

New Jersey Time to Care Coalition

Phone: 732.932.0081

Email:

Website:

Media Release Form

Initial Below:

_______ I am willing to be interviewed:

_____ I am willing to have a voice recording and photograph

included, and have my name, city and job title identified.

_____ I am willing to have my story shared, but would like my

identity to remain anonymous.

_______

My interactions, conversations, questions, and responses may be

included in the NJ Time to Care Coalition and Family Values at Work materials

(website, publication) and my name and job title may be identified.

_______

The NJ Time to Care Coalition may publish summaries of my statements and

make attribution without additional approval.

_______

Photographs/video taken by the NJ Time to Care Coalition staff or agents may

be used in our materials and in public relations.

Please type or print clearly:

Name: __________________________________________________________

Job title: ____________________________________________________

Agency: _________________________________________________________

City, State, Zip: ___________________________________________________

Address: _________________________________________________________

Phone: ______________________________ Fax: ________________________

______________________________________

__________________

Signature

Date

Thank you!

“Providing families with time to care means strong families, strong workplaces, and strong communities.”

Media Release Form Page 2