Media Access Informed Consent Form

Whereas, I _________( NAME)_______ , representing ____[Name of organization] _______, am about to travel with _______________, and Whereas, I am doing so entirely upon my own initiative (or my own and my employer's initiative) , risk and responsibility; and Whereas, I recognize that covering response/recovery operations at disaster scenes or elsewhere carries with it certain inherent risks to life, limb, and equipment; and Whereas, I recognize that the U.S. Department of Homeland Security (DHS) and the Federal Emergency Management Agency (DHS), and other organizational elements of DHS, in pursuing the accomplishment of its primary mission, cannot guarantee my personal safety or the safety of my equipment, and I understand that my acknowledgement and execution of this consent and release is a condition to being credentialed to have media access with agency operations and receiving agency assistance or coordination with respect to that coverage.

Now, therefore, in consideration of the permission extended to me, I do hereby for myself, my heirs, executors and administrators, (and on behalf of my employer, if any ) release, remise, acquit, satisfy, and forever discharge DHS and FEMA and its member officers, agents and employees acting officially or otherwise, from any and all claims, demands, actions or causes of action, on account of my death or on account of any injury to me or my property which may occur from any cause during my stay, travel, and all ground, flight or water operations incident thereto.

I also acknowledge receipt of and agree to abide by any media access ground rules which have been provided to me by the agency, and to withhold any sensitive information which may be accidentally or improperly disclosed to me during the period of granted access or travel. I agree that all interviews with agency employees or employees of agency contractors during the media access will be “on the record” unless stated otherwise. During my stay with____________, I will not interfere with any operations. I understand that failure to comply with these restrictions may result in the loss of my or my employer's authorization to accompany ___________ during mission operations or other agency activities, and may result in cancellation of my or my employer's participation in the agency's media access program.

I represent that I am authorized to execute this consent on behalf of my employer, if any.

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Signature

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Printed Name

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Date

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Media organization

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Address

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Phone

Please provide contact information for a person to be notified in an emergency (preferably next immediate relative):

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Witness

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Witness

Last Modified: Tuesday, 21-Oct-2008 13:37:18 EDT