[JRN 4100]

Video/Audio/Photo/Interview Release Form
Journalism at WMU News Website

Date: ____________________________________________
Name of Interviewee (Print):  __________________________
E-mail:  __________________________________________
Phone Number: ____________________________________
Name of Interviewer (Print):___________________________

I, the Interviewee, agree to be interviewed and videotaped/recorded/photographed for a story that may appear on the School of Communication, Journalism Program website (http://journalismatwmu.com/).

My signature below indicates my agreement to allow the interviewer to use my name, information I provide during the interview, and images taken during the interview.  My signature below indicates that I have been informed that I will be asked to check the accuracy of the information I provide for the story after the story has been written.  My signature below indicates that I have been informed that I am to check the accuracy of information and am not to alter direct quotes that I previously gave during the interview.

Signature of the Interviewee: ________________________________________________
Date:  ________________________________________________
Signature of the Interviewer:  ________________________________________________