Photo/Interview Consent and Release Form.

Thank you for wanting to be part of this project!!

Here's some boring paperwork that I advise you to read, sorry about that :)

Photo/Interview Consent and Release Form.

Without expectation of compensation or other remuneration, now or in the future, I give my consent to Laura Paulina Gonzalez Lopez (Strong Women of Coffee), her affiliates and agents and/or assigns, to use my image and likeness and/or any interview statements from me in publications, advertising or other media activities (including the Internet), with regard to and for use in her project Strong Women of Coffee only. This consent includes, but is not limited to:

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in publications, newspapers, magazines and/or other print media, television, radio and/or electronic media (including the Internet), theatrical media and/or in mailings;

(d) This permission includes such republication as may be made by persons or organizations of information, images, etc. taken from the Strong Women of Coffee publication.

This consent is given in perpetuity, and does not require additional future approval by me.

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