Audio/Video Consent and Release Form

For Zoom classes with Patricia Fields, PsyD.


Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to _Patricia Fields, PsyD, its affiliates and agents, to use my image and likeness and/or any  audio recordings, interview statements from me in its publications, advertising or other media activities (including the Internet). 


This consent includes, but is not limited to:


(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;


  (b) Permission to use my name; and or zoom nick name or identity


(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

This consent is given in perpetuity, and does not require prior approval by me.


Successfully submitted!
Thank you!