10P Program

10P Program

Media Consent & Release Form

Purpose of Consent

The 10P Program collects participant stories, testimonials, and experiences to communicate the impact of its programs to supporters, funders, partners, and the broader public. By completing this form, you grant the 10P Program permission to use your story, statements, and related information for outreach, educational, and fundraising purposes.

01

Participant Information

03

Authorized Use & Distribution

I understand that my story may be shared by the 10P Program and its grant partners or funding organizations in materials related to program impact. Authorized uses include, but are not limited to:

Print & Digital Media

  • Organizational website and blog
  • Social media platforms
  • Newsletters and email communications
  • Educational or promotional materials

Reports & Applications

  • Grant applications and progress reports
  • Foundation and funder reports
  • Annual and organizational reports
  • Donor and stakeholder communications

These materials may be distributed publicly or shared privately with donors, partners, and stakeholders.

04

Grant of Rights

By signing this form, I acknowledge and agree to the following terms regarding the use of my story, testimonial, likeness, and related materials:

a.
Perpetual License.I grant the 10P Program a perpetual, irrevocable, worldwide, royalty-free license to use, reproduce, modify, adapt, publish, translate, and distribute my story, testimonial, likeness, photographs, video recordings, and any related materials in any format or medium, whether now known or hereafter developed.
b.
Right to Edit.The 10P Program may edit, condense, or adapt my story and testimonial for clarity, length, or format, provided the edits do not materially alter the substance or intent of my statements.
c.
No Compensation.I understand that I will not receive any payment, royalty, or other compensation for the use of my story, testimonial, likeness, or related materials, whether now or in the future.
d.
Retention of Ownership.I retain ownership of my personal story and experiences. This agreement grants a license to use — not a transfer of ownership of — the materials described herein.

In summary: You keep ownership of your story. The 10P Program receives a permanent, royalty-free right to use the materials you provide for its mission-related purposes. Previously published materials remain in circulation even if you later withdraw consent for new uses.

05

Media & Photography Consent

Please select one of the following options regarding the use of your photographs or video recordings:

06

Privacy Preferences

Please select your preferred level of identification in published materials:

07

Participant Acknowledgments

1.My participation in this consent is entirely voluntary and will not affect my standing in the program.
2.I may request to review and suggest edits to my story before it is published.
3.I may withdraw my consent for future use at any time by providing written notice to the 10P Program.
4.Any materials already published or distributed prior to withdrawal may not be able to be fully recalled or removed.

Release of Liability

I hereby release and hold harmless the 10P Program, its officers, employees, agents, and affiliated partners from any and all claims, demands, or liabilities arising from the use of my story, testimonial, likeness, or related materials as described in this consent form.

08

Signatures

Sign here

By submitting, you confirm that all information provided is accurate and that you agree to the terms outlined above.

Progress38%