Client Publicity and Media Release Form

Today's Date *

I am: *

the Client
Parent of minor child who is the client
Managing conversvator of minor child who is the client
Guardian of the adult client

Name of Parent/Guardian/Managing Conservator *

First Last

Name of Client *

First Last

Name of attorney or advocate who worked on my case

Email *

Enter Email Confirm Email

Phone (mobile number is preferred) *

I prefer to be contacted by: *

Email
Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I agree that for publicity purposes, DRTx may use (CHECK ALL THAT APPLY): *

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

What languages do you have fluency in speaking?

English
Spanish

Availability for News Interviews *

Please let us know days of week and times of day you are available for possible interviews with reporters.

Other Information *

Is there any other information you would like for us to know? If not, just type in "no"

Agreement *

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. *