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Client Publicity and Media Release Form
For clients (or their legal guardians) to complete giving DRTx permission to share your story for publicity purposes.
"
*
" indicates required fields
I am:
*
Required
The client
The parent of a minor child who is the client
Managing conservator of a minor child who is the client
Guardian of of an adult client
Name of Parent/Guardian/Managing Conservator
*
Required
First
Last
Name of Client
*
Required
First
Last
Email
*
Required
Enter Email
Confirm Email
Phone (mobile number is preferred)
*
Required
I prefer to be contacted by: (check all that apply)
*
Required
Email
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name of attorney or advocate who is working on OR worked on my case:
I agree that for publicity purposes, DRTx may use (CHECK ALL THAT APPLY):
*
Required
(Publicity purposes include but are not limited to annual reports, newsletters, website, social media, videos, press releases, donation campaign messaging, etc. DRTx will not sell or otherwise use the material for commercial purposes.)
General information about how DRTx assisted me or my child
Use of first and last name
Use of first name only (of client/child/parent)
Photographs I have given DRTx, that DRTx has taken of me, or that are available online
A video that DRTx has taken of me, one that I have provided to them, or one available online
What is your primary language spoken?
ASL
Chinese
English
Spanish
Vietnamese
Other
If you speak additional languages, please list below:
If you are participating in news interviews:
If you are agreeing to talk to reporters, please let us know days of week and times of day you are available to talk to reporters. (If this does not apply to you, you can skip the question.)
Other Information
Is there any other information you would like for us to know?
Agreement
*
Required
Please check "I agree" below to give permission to Disability Rights Texas to use the above that you have selected for publicity purposes. After this you will also be asked to type out your first and last name and the date to confirm your agreement.
I agree.
In addition to checking "I agree" above, please also type your first and last name and today's date indicating your agreement.
*
Required
