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Client Publicity and Media Release Form
Authorizations to use photographs and information for publicity purposes
"
*
" indicates required fields
I am:
*
Required
the Client
Parent of minor child who is the client
Managing conservator of minor child who is the client
Guardian of the adult client
Name of Parent/Guardian/Managing Conservator
*
Required
First
Last
Name of Client
*
Required
First
Last
Name of attorney or advocate who worked on my case
Email
*
Required
Enter Email
Confirm Email
Phone (mobile number is preferred)
*
Required
I prefer to be contacted by:
*
Required
Email
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
I agree that for publicity purposes, DRTx may use (CHECK ALL THAT APPLY):
*
Required
Publicity purposes include but are not limited to publishing the material in/on annual reports, newsletters, websites, social media, press releases, donation campaign messaging, etc. in order to show the kind of work conducted by DRTx. DRTx will not sell or otherwise use the material for commercial purposes.
General information about how DRTx assisted client in the case
Photographs I have given DRTx
First name only of client
Full name of client
Photographs taken by DRTx
Photos available online
A video recording of an online or in-person legal clinic in which I was a participant
What languages do you have fluency in speaking?
English
Spanish
Vietnamese
Chinese
Other
Availability for News Interviews
*
Required
Please let us know days of week and times of day you are available for possible interviews with reporters. (If this does not apply to you, type N/A.)
Other Information
*
Required
Is there any other information you would like for us to know? If not, just type in "no"
Agreement
*
Required
Please click next to the agree button below to give permission to Disability Rights Texas to use all above that you have selected for publicity purposes as stated. 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 clicking on "I agree" above, please also type your first and last name and today's date indicating your agreement.
*
Required
