A Special Community: Interviewee Requirements

A Special Community: Interviewee Requirements

Hey everyone. One thing to note: The Facebook Live will require a webcam (can't do the interview via the phone).

Name
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First Last
Email *
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Phone number *
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Short bio (it can be just a few sentences if you'd like) and your social media handles. *
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4 or 5 high-resolution images to include in the video (head shot, family photos, action shots, etc.) *
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Upload file Capture image using webcam
Any self-advocates you know who may make sense for a future interview to spotlight their story? Please include their name(s) and email address(es) below!
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Would you like to make a one-time donation to our nonprofit so I can spend more time producing these self-advocate videos? *
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Would you like to become a supporter for a cup of coffee ($5) a month so I can do this work more often? You'll receive exclusive content for joining (e-books, behind the scene videos, etc.) *
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Would you like to start a Facebook Fundraiser/GoFundMe to support our nonprofit so I can spend more time producing these self-advocate videos? (I'll send you a Youtube video on how to create one in just 2 and a half minutes) *
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Media Consent and Release Form
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to KERRY & KFM Making A Difference and Kerry Magro (“KERRY & KFM”), its affiliates and agents, to use my/my child’s name, image and/or any interview statements from me/my child, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including DVDs and the Internet), in theatrical media, in mailings for education and awareness, advertising, or other media activities (including the Internet). I further grant the right to KERRY & KFM to edit, use and reuse said materials and information, and consent to waive any right to approve or disapprove the final content created by KERRY & KFM, which uses the above-mentioned materials and information. Additionally, in signing this form, I release KERRY & KFM from any liability arising from KERRY & KFM’s use of my/my child’s essay/photo/image/likeness/statements.
By consenting to the above and waiving my and/or my child’s rights, I acknowledge that KERRY & KFM may use my/my child’s name, likeness, interview statements, and other information in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media, in mailings for education and awareness, advertising, or other media activities (including the Internet). I/my child acknowledge and agree that I/my child has rendered services to KERRY & KFM as an independent contractor. However, for copyright purposes, the undersigned shall be deemed an “employee-for-hire” of KERRY & KFM, and it is understood and agreed that all results and proceeds of my/my child’s services for KERRY & KFM hereunder shall be deemed “work-made-for-hire” specifically ordered or commissioned by KERRY & KFM under the U.S. Copyright Act of 1976, as may be amended from time to time hereafter and all other applicable copyright laws, and from its inception, KERRY & KFM shall be deemed the sole owner and author thereof. Accordingly, KERRY & KFM shall exclusively own all worldwide rights, title and interest (including without limitation, all copyrights [and all renewals, revivals, and extensions thereof]) in and to the content created and/or featuring me/my child, which uses the above-mentioned materials and information, and may exploit all now known and/or hereafter existing rights of every kind and nature in and to the above-referenced content throughout the universe, in perpetuity.
I am signing this release form with the knowledge that any photos/images/videos posted on KERRY & KFM’s website(s) can be downloaded and reprinted by various news organizations, including print, electronic and broadcast media, and I, therefore, release KERRY & KFM from any liability arising from use of my/my child’s photos/images/videos in KERRY & KFM’s website postings. Additionally, I understand that there are potential dangers associated with the posting of personally identifiable information on a website, since global access to the Internet does not allow for control of who may access such information.
This consent is given in perpetuity and does not require prior approval by me.
Your Name, Address & Date For Media & Consent Form *
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Media Release & Consent Form Signature *
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E-Signature Field
Clear
The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child. Please write down your Name & Date
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Signature of Parent or Legal Guardian
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E-Signature Field
Clear
Please list upcoming Monday/Thursdays at 7PM EST for the next 4 weeks you'd be available for a 1 hour interview in addition to any days/times that work best for you if those 2 times don't work (3 ideal dates/times would be great!) *
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A Special Community: Interviewee Requirements

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