"Media Release Form" - Vermont

This "Media Release Form" is a document issued by the Vermont Department of Corrections specifically for Vermont residents with its latest version released on May 1, 2013.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Vermont Department of Corrections.

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VERMONT DEPARTMENT OF CORRECTIONS
MEDIA RELEASE FORM
Inmate’s Name: _________________________________ DOB: ________________________
Media Organization: ___________________________________________________________
I, the above named individual, freely give permission to the above named media
organization to publish my name and information. I grant these permissions freely and
voluntarily and further agree to hold the Department of Corrections harmless from any
and all actions that may arise as a result of this media representation. I further
acknowledge that my consent to such use of this information is done without monetary
advantage.
I understand that the Department of Corrections and the media organization retains the
discretion whether to use this information or not.
Inmate Signature: ____________________________________ Date Signed: ____________
Witness Signature: ___________________________________
Date Signed: ____________
VERMONT DEPARTMENT OF CORRECTIONS
MEDIA RELEASE FORM
Inmate’s Name: _________________________________ DOB: ________________________
Media Organization: ___________________________________________________________
I, the above named individual, freely give permission to the above named media
organization to publish my name and information. I grant these permissions freely and
voluntarily and further agree to hold the Department of Corrections harmless from any
and all actions that may arise as a result of this media representation. I further
acknowledge that my consent to such use of this information is done without monetary
advantage.
I understand that the Department of Corrections and the media organization retains the
discretion whether to use this information or not.
Inmate Signature: ____________________________________ Date Signed: ____________
Witness Signature: ___________________________________
Date Signed: ____________
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