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Media Release Form 

for the NC Waiver Action Team

I hereby authorize the North Carolina Waiver Action Team to use my or my child’s photo and/or information related to my experiences with the NC Innovations Waiver.

I understand this information may be used on our NC Waiver Action Team Website, audiovisual presentations, promotional literature, community presentations, letters to area legislators and media and/or other similar ways. 

My consent is freely given as a public service to the NC Waiver Action Team without expecting payment. I release the NC Wavier Action Team and their representatives from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, videotape and/or photographs. 

I prefer that (choose one):
My (or my child’s) complete name be used.   

My first name only be used. 

I understand that I can revoke this release any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease. 

_________________________________ Printed Name 

_________________________________ Signature 

_________________________________ Date