American Kratom Association
”Kratom Changes Lives” Video Contest
Actor Release Form
This form is required by each person who is interviewed in the video or serves as an actor/extra (excluding those listed as primary contact and student contributors).
*If you film in a public area (i.e., public park, shopping center), you do not need a consent form for each individual who is indirectly captured in the background.
Video Title ___________________________________________________________________________
Primary Contact _______________________________________________________________________
Actor’s Name _________________________________ Date of Birth ___________________________
I acknowledge that images and/or voice recordings of me (or my child) are included in a video that was submitted to the American Kratom Association’s (AKA) as part of its “Kratom Changes Lives” Video Contest. I grant full authority for the AKA and anyone authorized by the organization to share, reproduce, and/or exhibit these images/voice recordings without restriction. I acknowledge that I (or my child) will not be compensated.
Actor Signature Actor Name (Please Print)