INTERVIEW CONSENT FORM

Interview Date: [MM/DD/YYYY] Approximate Duration: [APPROXIMATE DURATION]

Location: [INTERVIEW LOCATION]

This form documents your permission for [INTERVIEWER’S NAME] (“Interviewer”) to interview you for the purposes of [DESCRIBE PURPOSE OF INTERVIEW].

1. I, [PARTICIPANT’S NAME], agree to participate in the interview and consent to being recorded during the interview as outlined below: (check all that apply)

☐ – Audio Recordings. I consent to being audio recorded during the interview.
☐ – Video Recordings. I consent to being video recorded during the interview.
☐ – Photographs. I consent to being photographed during the interview.

2. I understand that any audio recordings, video recordings, and photographs taken of me during the interview may be published, displayed, and/or broadcasted in print, web, digital display, and all other forms of media.

3. I understand that I may withdraw my consent at any time without penalty by giving written notice to the Interviewer at [INTERVIEWER’S ADDRESS]. If I decide to withdraw, I understand that I can request the removal of my interview materials from any future publications, although it may not be possible to remove content that has already been published.

4. I understand that the Interviewer may identify me by name in any interview materials used.

5. I have been told how the interview information, photographs, audio recordings, and/or video recordings will be used and the purpose of the interview.

6. I understand that I will not receive any benefit or payment for my participation.

7. I give permission for the interview materials to be used for any and all legitimate purposes, including advertising, trade, promotion, and exhibition, and for use by third-party media companies.

8. I understand that the interview materials become the property of the organization that creates and publishes such items, and I give up all rights to these materials.

9. I understand that it is impossible to control the use of photographs, audio recordings, video recordings, and interview information once these items are made public, and I understand that the Interviewer has no control over what others may do with them. Various postings may occur on internet websites, including YouTube, Twitter, Facebook, and so forth. These materials may continue to exist and be accessible in some form in the future.

By signing below, I confirm my understanding of the above information and release the Interviewer from liability from any claims, costs, expenses, and damages that might result from the interview information, photographs, video recordings, and/or audio recordings being used.

Participant Signature: _____________________________ Date: ________
Printed Name: _____________________________