Name *

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

How can we use your name if we share your story?

First name only

First and last name

Do not use my name (just list "ARCH Homeowner")

Release Form

I, the undersigned participant, give my permission to have video and/or photos taken and to have quotes by me used by A Regional Coalition for Housing (ARCH). I also give permission for the quotes, video and/or photograph(s) to appear on the ARCH website, and/or print publications. Neither I nor any participants will receive compensation of any kind for appearing in such photos and/or videos. There is no guarantee that shots of me will be used. No part of the video(s) and/or photo(s) is to be sold to any outside parties. Any photos, videos or quotes are subject to release to the public pursuant to public disclosure laws.

I agree to this release form

I do NOT agree to this release form