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 ___________________________



Actor Release:


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)



Date ________________________________


CALL- 804-552-1252 or EMAIL:

At this time we can not recommend vendors.   Please join a support group on FaceBook or Reddit for help with vendors and general kratom questions.

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