NJ-CARS Media Consent - Faces & Voices of Recovery Data Hub

Participant Name*
First Last
Date of Birth*
YYYY dash MM dash DD
Status
- I am a current Participant
- I am completing this form to become a Participant
Home Address*
If current address does not exist please use NA

Street Address Address Line 2 City State ZIP Code
My Program is:*
- Prevention Links
- CLEAR
- Family Support Center
- OHH 2020
- Recovery Center - PL
- Restore
- RHS
- STAR
- UCHH365
- NuDay
Race*
- White
- Hispanic, Latino, or Spanish Origin
- Black or African American
- Middle Eastern or North African
- American Indian or Alaska Native –
- Asian –Native Hawaiian or Other Pacific Islander
- More than one race
- Other
Gender*
- Male
- Female
- Other
- Nonbinary
Primary Phone
Participant Email
MEDIA CONSENT FORM
I hereby consent to participate in participant success stories during any part of my recovery process. Prevention Links is also granted editorial license to edit all corresponding content and media without the need for further permission, which this Consent Agreement hereby provides.
I grant Prevention Links and affiliates to use my full name.*
- Yes
- No
I grant Prevention Links to use my full first name and last initial.*
- Yes
- No
I grant Prevention Links to use my story but with a false name.
- Yes
- No
If you are an Operation Helping Hands participant: I grant Prevention Links the right to include my contact information to the Prosecutors Office, Office of the Attorney General, and affiliates to be contacted for questions regarding my story and OHH process.
I understand that Preventions Links is not obligated to use any of the aforementioned materials in which I, my children and/or my family may appear. In the event that Prevention Links does use any of the aforementioned, Prevention Links retains the right under the perpetual license to edit any and all related materials at any time. I hereby waive the right to inspect, review, and/or approve any use in advance of, during or following preparation, distribution and publication. I hereby unconditionally release Prevention Links any of its agents, employees, and affiliates from any and all claims, demands and liabilities whatsoever in connection with this Agreement and with any of the material published in accordance with this Agreement. By signing below, I represent that I am of legal age, have full legal capacity and am authorized to sign on behalf of myself. I agree that I may not revoke this Agreement and will not deny the existence of This Agreement in whole or in part at any time. I have read the foregoing in its entirety and fully understand its contents and its meaning.
Consent*
I agree to the media consent policy.
Complete Forms with Signature
Participant Signature*
Date*
MM slash DD slash YYYY
Signature Witness
Witness Name