Haven House Ministries Media Consent

Participant details

Full name Preferred name Email Phone Date of recording

Age and guardian

Are you 18 or older? Guardian full name (if under 18) Guardian email Guardian phone

Consent choices

Please review the choices below and select whether you consent to be recorded. You can include any limitations in the notes.

I consent to be recorded and used in media. I do not consent to be recorded.

I grant permission to use my image, voice, and likeness in photos, video, audio, livestreams, social media, print, and online materials created by Haven House Ministries. I understand there is no payment or compensation for this use. I release Haven House Ministries and its representatives from liability related to this use.

Notes or restrictions (optional)

Signature

Typed signature (full name) Signature date

By typing your name, you confirm this is your electronic signature and you agree to the selections above.

Admin access

Enter the admin PIN to view responses.

Admin dashboard

Track responses, filter by status, and export a CSV of entries.

Total responses

Accepted

Declined

Date	Name	Contact	Status	Notes