Sample minor interview consent form

This is a sample release form for the non-commercial use of material provided by a minor to student media. Its primary purpose is to protect student media from claims of invasion of privacy or libel. It is assumed here that the minor is capable of providing informed consent. For very young children or other individuals incapable of fully understanding the nature and ramifications of their consent, the signature of a parent of legal guardian is required.

This form is meant to provide general guidance only and is neither intended nor represented as a substitute for obtaining case-specific advice from a licensed, local practicing attorney experienced in media law. The Student Press Law Center accepts no responsibility for liability that may result from the publication of unlawful material.

Release

I hereby grant The Student Times permission to use any or all information obtained during the interview conducted on March 14, 2008, and in subsequent contacts, related to my experiences as a teenage mother. I also grant The Student Times permission to use any photograph or likeness of me taken by The Student Times photographers.

I understand that information from my interview and any photos may be used in a story to be published in The Student Times, the student newspaper at Central High School. I understand The Student Times is distributed both on school, throughout the community and nationally, for example, to paid mail subscribers and at student press conventions. I also understand that the story may be reproduced on The Student Times Web site, which can be read by anyone in the world with access to the Internet, and may be available for years to come. I have been advised by The Student Times staff that, as a minor, I may wish to discuss my decision to consent to such publication with my parents and others whose opinions I respect. I am providing permission to The Student Times to use my information and photographs of my own free will because I believe others may benefit from knowing of my experiences.

Specifically, my permission includes the following:

  1. The right to publish and republish, at any time, the above information or photos in The Student Times, on The Student Times Web site and in any subsequent medium for any noncommercial purpose, including promotion of The Student Times;
  2. The right of The Student Times or individual authors or photographers to copyright such information or photographs in their own name;
  3. The right of The Student Times to use my name in connection with such information or photos if it chooses.

I waive any right to inspect or approve the finished story or stories, photographs or other uses of my information that may be published.

In consideration of my participation, I understand that, at my request, The Student Times will provide me with up to ten copies of any issue that contains information or photographs related to me at no charge.

I hereby release and discharge The Student Times, its staff members, Central School District and its employees from any claims and demands arising out of or in connection with the use of the information or photographs described above, including any claims for libel or invasion of privacy.

I have read the above release prior to signing it and am fully familiar with its provisions.

Name (print full name):__________________________

Signature:_______________________________________

Date:____________________________

Address:____________________________

City, State, Zip:______________________________

Telephone:__________________________

[If a parent or guardian also signs, the following should be included:

I, __________[print full name]________ , am the parent/legal guardian of the individual named above. I have read this release and approve its terms.

Signature__________________________________

Date:_____________________

Witness (print full name):_________________________

Signature:______________________________

Date:__________________________________