Interview Permission & Release Form

Please fill out this form to grant permission for conducting and recording your interview with the African American Quilt Documentation Study Group.

Personal Information

First Name *

Last Name *

Professional Title (if applicable)

Email *

Phone Number

Street Address

Street Address Line 2

City

State

Zip Code

Purpose of the Interview *

Date of Interview

I give consent to be interviewed. *

yesno

I give consent for the interview to be audio and/or video recorded. *

yesno

I give consent to share the content of the interview publicly. *

yesno

Full Name (as signature) *

Date Signed *

Fields marked * are required.