Consent for Media Recording(s)

Name of Subject (required)

Name of Caregiver or Representative (if different from subject)

Contact Email (required)

Contact Phone Number (required)

Name of AuthoraCare Representative

Type of Media (check all that apply): PhotographVideoAudioInterviewOther

I hereby consent to the use by AuthoraCare Collective of recorded media (identified above) featuring the subject above for production in AuthoraCare's agency materials.

Type Name to Electronically Sign (required)

By checking this box, I hereby verify the above electronic signature on this document, attest to my legal right to sign on behalf of the subject, and affirm that this electronic signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.