Please fill the form below to participate

Strathmore University and its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the internet with social media).
This consent includes, but is not limited to:
(a) Permission to interview, film, photograph, tape, audio 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 its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet with social media), in theatrical media and/or in mailings for educational and awareness.  
I understand that I am not entitled to receive any payment in consideration for the use of details related to my person as set forth above, in the photographs pursuant to this declaration of consent.
This consent is given in perpetuity, and does not require prior approval by me.