ADL Basic Form Template

New Yorkers in Their Own Words

First Name

Last Name

Zip Code

Email address

Occupation

How you want to share your experience/your words? (Upload video, image or written message)

What message would you like to share?

RELEASE AND PERMISSION FORM

STORY RELEASE

I hereby grant permission to ADL to use my story in any and all publications, applications, including print, electronic or Web.

I acknowledge and understand that once my story is posted on ADL’s website or on other Internet sites or applications that it will be available to anyone anywhere and can be downloaded by anyone with internet access.

I acknowledge and understand that my decision to sign or not to sign this form will not change my relationship with ADL in any way.

This has been explained to me by an ADL Staff member in a language I understand. I have had the opportunity to ask questions. I acknowledge that I make this decision freely.

Please check one:

YES, you may use my real name (first name only), my profession if applicable, and my city with my storyNO, you may NOT use my real name (first name only), my profession if applicable, and my city with my story

PHOTO RELEASE

I hereby grant permission to the Anti-Defamation League, its subsidiaries and affiliates (“ADL”) to photograph, film, videotape or otherwise record me or my voice and use my picture, voice, silhouette and other reproductions of my physical likeness in connection with the above event. I also grant ADL the right to publish, exhibit, display, copyright, license, transfer, edit, or in any other way use (“publish”) in any form, without prior approval, any photographs taken at the above event, for any purpose whatsoever, including without limitation educational, commercial, trade and pictorial art, with or without my name or any other identification and with or without the names of any other real or fictitious persons. I further give ADL the right to reproduce in any manner whatsoever any recordings made by ADL of my voice and all instrumental, musical, or other sound effects produced by me. I hereby release ADL and the officers, directors, employees, agents, members, associates, successors, licensees, and assigns of ADL from any and all liability for damages for libel, slander, invasion of privacy or any other claims based on the publication of such photographs, or recordings. My signature indicates that I understand the foregoing and fully understand the meaning and effect thereof and intend to be legally bound.

Signing your name below counts as your signature to the release.

Signature Name

Date

Contact Information