Media Release Forms

Thank you for participating with us.

Please sign the media release form below to give us final permission to use your picture or video.

If you have any questions, please contact our Research Team at 440-260-8865 or research@ohioguidestone.org.

OhioGuidestone Media Release

I, on my own behalf and, if applicable, on behalf of the minor child named above (“Releasor”), consent to OhioGuidestone and its subsidiary organizations, including A Renewed Mind (collectively the “Agency”), using Releasor’s name, likeness, voice, interview, and personal information, including protected health information and substance use disorder information (“Information”) on the terms described below. The Information may be contained in, without limitation, photographs, interviews (with myself or others), anecdotes (from myself or others), and other recordings (“Media”). The Agency may use the Media in promotional and other public materials to support the work of the Agency.


You consent to and authorize the use of any and all Media that the Agency has regarding Releasor, and of any reproductions of the Media, for any purpose whatsoever, in any medium whatsoever, including, but not limited to, advertising fliers, pamphlets, websites, videos, e-mails, social media, blogs, publications, billboards, posters, signs, and magazines. You also consent to the use of Releasor’s name in connection with the Media. You agree that the Media may also be used without identifying Releasor as its subject, at the Agency’s discretion. You understand that information used or disclosed according to this Media Release may be subject to re-disclosure by the recipient and may no longer be protected.


You agree that the Media, including any negatives and digital copies, shall be the sole property of the Agency, with full right of disposition in any manner whatsoever. The Agency will have the right, among other things, to edit the Media and compile it with other text, graphics, and photographs to create promotional and other materials. You hereby waive any right to inspect or approve the finished product or any written copy that may be used in connection with the Media.


You, on your own behalf and, if applicable, on behalf of the minor child named above, release and discharge the Agency and its agents, representatives, and assignees from any claim or cause of action now known or later discovered for, without limitation, invasion of privacy, right of publicity, and defamation arising out of the use, exploitation, and publication of the Media.

Dated Signatures

This electronic signature holds the same force and effect as an in-person signature.
This electronic signature holds the same force and effect as an in-person signature.