Sample ​Interview Release Form
 
Name of Storyteller: ____________________________________________________
 
Date/Time/Place of interview: _____________________________________________
 
Interviewer’s name:_____________________________________________________
 
Project Name: ________________________________________________________
 
Contact details (Address/Phone/Email):_______________________________________
 
Age/Date of Birth: _____________________________________________________
 
By signing the form below, you give your permission for the interview and/or video and/or audio made during this project to be used for publication purposes including exhibitions, internet, and presentations. Should you have any specific restrictions or agreements, please indicate them below:
 

 
I agree to the uses of these materials described above, except for restrictions outlined above.
 
Name (please print): __________________________________________________
 
Signature: _________________________________________________________
 
Date: ____________________________________________________________