Media Disclosure Form - 2024


Station ID:    

Participant Name:  

Parent/Legal Guardian Name:  



City, State:  



Family Stations, Inc. is a Christian nonprofit radio ministry whose mission is to share the Word of God and a message of hope in Jesus Christ with people throughout the United States and around the world (“Mission”). I would like to help Family Stations, Inc. spread that Good News by allowing it to use my Likeness and the Materials, as defined below.


In consideration for the opportunity to help Family Stations Inc. further its Mission, I authorize Family Stations Inc., its affiliates, successors, and assigns, and the employees, agents, and representatives of each (“Family Radio”) to use my biographical and personal information that I share with Family Radio, city and state of residence, likeness, image, name, signature, voice, testimony, and other statements (“Likeness”) for any purpose and in any manner that Family Radio determines, in its sole discretion, will help Family Radio further its Mission, including for fundraising and promotional purposes, without payment to, or further consent from, me. I understand that Family Radio will create, or have created on its behalf, materials that incorporate my Likeness (“Materials”), and I irrevocably authorize Family Radio and its licensees to edit, copy, create derivative works using, perform publicly, distribute copies to the public of, or publicly display my Likeness and the Materials on a perpetual, unrestricted, and worldwide basis in any format, including photos, print, or audio and audiovisual recordings. I authorize Family Radio to make the Materials available through any medium, including television, radio, or satellite transmissions, social media postings, podcasts, or other physical or electronic media now known or later created.

Family Radio’s Rights in the Materials

I irrevocably transfer and assign to Family Radio my entire right, title, and interest, if any, in and to the Materials. I understand that I have no right to inspect or approve the Materials before they are used by Family Radio or its licensees, receive notice of their use or publication, or receive any payment for their use.


I irrevocably release Family Radio and its licensees from all legal and equitable claims that I may have related to Family Radio’s use of my Likeness or the Materials, including, without limitation, any claims relating to copyright, trademark, or patent infringement, trade secret misappropriation, rights of publicity or privacy, defamation, libel, false light, or moral rights.


  • I am the participant named below and am 18 years of age and competent to contract in my own name; or
  • if the participant named below is under 18 years of age, I am the participant’s parent or legal guardian, have the legal right to consent to, and, by signing below, do consent to the terms and conditions of this Release on behalf of myself and the participant.

If this Release is signed electronically, I agree that my electronic signature below is intended to authenticate this writing and to have the same force and effect as a manual signature.

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Document name: Media Disclosure Form - 2024
lock iconUnique Document ID: 475462e3a7e6aed738e11c25323b982851ba232b
Timestamp Audit
February 12, 2018 3:00 pm EDTMedia Disclosure Form - 2024 Uploaded by Jennifer Burkhiser - IP