Amputee Coalition’s Media Consent Form
This consent gives the Amputee Coalition for America permission to use my name, likeness, image, voice, story, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, quotes, print or online written documents, and the like, taken or made on behalf of Amputee Coalition activities. I grant the Amputee Coalition ownership of such pictures, etc., including the entire copyright, and affirm they may use them for any purpose consistent with the Amputee Coalition’s mission.
These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the internet and social media. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc., and hereby release the Amputee Coalition and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.
Choice /Opt-out
- If you need to request changes to your media consent, please contact us at:
Send an email request to: Communications@Amputee-Coalition.org - Call toll-free: 1-888-267-5669
- Mail your request to: Amputee Coalition 601 Pennsylvania Avenue NW, Suite 420, South Building, Washington, DC, 20004.
When sending a request, please include your full name, address, phone number, email, and include what specifically you are requesting to change.