Guided Path Media Information Form and Release

Thank you for participating in Guided Path’s efforts to raise awareness and share stories of impact. Please complete this form to provide us with key details about you or your involvement.

Participant Information

First name

Last name

Birthday

Phone

Representation Details

Type of Cancer (if applicable):

Stage (if applicable):

Organization Affiliation (if applicable):

Story Information

Would you like to share your story?

Yes

If yes, please provide a brief overview of your experience with cancer or your connection to Guided Path:

Any specific aspects of your story you'd like to highlight?

Media Details

Type of Media Participation (select all that apply):

Photograph

Video Recording

Voice Recording

Written Testimonial

How do you prefer to be identified in our materials?

First Name Only

Full Name

Anonymous

Consent and Privacy Preferences

May we share your story/media publicly?

Yes

Are there any restrictions on how we can use your image or story?

I grant Guided Path Terminal Cancer Support (“Guided Path”) and its authorized representatives the irrevocable right and permission to use my photograph, video image, voice recording, and/or any other likeness of me (collectively referred to as “media”) for the following purposes:

Marketing materials (e.g., brochures, flyers, posters)
Website content and social media platforms
Advertising and promotional campaigns
Fundraising initiatives
Educational or advocacy purposes

I understand that the media may be edited, published, or distributed by Guided Path for these purposes without additional notification, permission, or compensation to me.

Terms and Conditions

Usage Scope: I understand that the media may be used in print, digital, and electronic formats and may appear in a variety of publications or platforms, including but not limited to social media, newsletters, and press releases.
Ownership: I acknowledge that all media produced by or on behalf of Guided Path is the property of Guided Path Terminal Cancer Support.
No Misrepresentation: Guided Path will not intentionally use the media in a way that misrepresents me or compromises my personal integrity.
Revocation: I understand that I cannot revoke this consent once the media has been published or distributed.

Confidentiality and Privacy

Guided Path respects your privacy. Any sensitive personal information shared during media collection will not be disclosed without your express consent.

Acknowledgment and Consent

By signing below, I acknowledge that:

I have read and fully understand the terms of this release.
I am of legal age (18 years or older) or, if a minor, my parent/guardian has signed below.
I voluntarily agree to the terms outlined above.

Name (Printed):

Signature

Date

If under 18, Parent/Guardian Name (Printed):

Parent/Guardian Signature:

Date

Parent/Guardian Phone:

Parent/Guardian Email: