Information Release Form
RequiredRequired Question(s)
Required 1.
I, [type your name], authorize Origin SC and its divisions to use my information specified below. It may be used, reproduced, and/or published for online, print, and air usage without compensation. I understand that this material may be used in various publications, public affairs releases, and broadcast public service advertising (PSAs) or for other related endeavors. It may also appear on Origin SC's website and /or related social networking pages. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, Origin SC and its divisions may publish materials, use my name, photograph, and/or make reference to me in any manner that they deem appropriate in order to promote/publicize the agency and/or its programs. Please type "no" if you do not consent to these conditions.

 

50 characters left.
Required 2.

Please initial if you consent to the publicizing of your real name. Type "no" if you prefer to remain anonymous.
 

 

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Required 3.

Please initial if you consent to the publicizing of your PHOTOGRAPH or VIDEO. Type "no" if you prefer that we not use your photograph or video.

 

50 characters left.