Appendix D: Media Release

Media Release
DO-IT Scholars Program
University of Washington

Members of the news media (print, broadcast, and electronic) often express an interest in covering DO-IT programs. News people may film, tape record, or photograph various activities. If participants object to being included in news coverage in any way, they should simply tell the reporter that they do not wish to be included.

If a reporter or other member of the news media asks us for information about you, we will provide them with a copy of this form. Please fill in the information, if any, you would like to share with a reporter.

Name of DO-IT Scholar: _______________________________________________________

Hometown: _________________________________________________________________

School: _______________________________ Year in School: ________________________

Disability:___________________________________________________________________

Phone Number(s):____________________________________________________________

E-mail Address(es):___________________________________________________________

Other Comments: ____________________________________________________________

Signature of DO-IT Scholar: _____________________________________________ Date: ______________________

Parental Permission Statement

I ___________________________________________ (Name of Parent/Guardian) hereby certify that I am the parent or guardian of _________________________________________________________ (Name of Participant).

I hereby consent to his/her wishes as set forth in the release herein above.

Signature of Parent/Guardian: _____________________________________________ Date: ______________________

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