Multimedia & Communications Release Form

With your permission, we may share your story in print, online, or on social media.

Please read and sign this Personal Information Release Form, which gives Wilder permission to share your and/or your child’s story, image, or voice publicly. With your consent, we may feature this content on our website, social media, podcast, or other public materials to help share the impact of our work.

Comments

This field is for validation purposes and should be left unchanged.

What information are you sharing with us? Wilder has my permission to use and let the public see my and/or my child's: (select all that apply)(Required)

Stories/interviews

Audio recordings

Photographs, pictures and images

Video recordings

All of the above

Can Wilder share your name and/or your child’s name? (select one)(Required)

Yes, I DO give Wilder my permission to ALSO use and let the public see my name and/or my child’s name along with the information selected above.

No, I DO NOT give Wilder my permission to ALSO use and let the public see my name and/or my child’s name along with the information selected above.

Wilder has my permission to use my information for a specific event or purpose only

Please describe the purpose or event above

Your First & Last Name(Required)

First Last

Your Child's First & Last Name

First Last

I understand that by signing below, I voluntarily give Wilder permission to share my information.(Required)

Please use the grey box below to sign this form using your mouse (if using computer or laptop) or finger (if using phone or tablet).

Email(Required)

Phone(Required)

Address(Required)

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

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Privacy Notice

The information you give to us in this form will be used to determine service requests and may be shared with other staff at Wilder whose jobs require access or with others outside of the Wilder Foundation as provided by law. You can also review our full privacy policy here.

Please note that you are not required to submit your information using this form.
You may also contact us at [email protected] if you have any questions.

Multimedia & Communications Release Form

Multimedia & Communications Release Form

Privacy Notice

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