Non Client Media Release Form

Today's Date *

Name *

First Last

Are you 18 years old or more? *

Yes
No

Mobile number *

Email *

Enter Email Confirm Email

I prefer to be contacted by: *

Email
Phone
Either are fine

I agree to give DRTx permission to provide the following information about me to news reporters and staff for the purpose of media conducting interviews with me for radio, TV, newspaper, etc. *

check all that apply

My first and last name
My email address
My cell phone number

What languages do you have fluency in speaking?

English
Spanish

Availability for News Interviews *

Please let us know days of week and times of day you are available for possible interviews with reporters.

Is there any other information you need for us to know?

Agreement *

Please click next to the agree button below to give permission to Disability Rights Texas provide your contact information to news reporters/staff.

I agree.