This is a template to help you gain informed consent from your story contributors.

Please use this free resource as a starting point in creating your ethical storytelling toolkit. It is very important that you consider all the ways in which you might customize and contextualize this form to your particular community. In the process of customization, you may choose to use different words, ask different questions, or present the form in a more culturally appropriate manner. This generic template was created for the sole purpose of providing you a tool that you can easily adapt and modify. 

The first section informs the contributor of their rights and sets expectations about the story’s use. Please review this information with the contributor verbally and answer any questions they may have.

The second section is to be completed by the contributor around permission and privacy considerations.

To download an unbranded copy of this form in MS word that you can customize for your organization, click the button below:

Download MS Word Version

Section 1

Service Guarantee

Sharing your story or experience is your decision. The organization will not offer additional resources or benefits to you for sharing your story. Likewise, if you choose not to share your story, you will not lose access to the resources and benefits you currently have through our programs.

Why we are asking for your story

  • Educate our audiences and increase their understanding of our work
  • Inspire audiences to support our work by donating money, volunteering, or advocating for our cause.

Generic responses are provided above. Please customize these to your mission and program. 

How we will use your story

  • We may or may not tell your full story, or share every detail you provided us.
  • Additional context around your story may be added to enhance our audiences’ understanding.
  • We may share your story, your image, or parts of your story in multiple formats, including websites, videos, email, and social media.
  • We strive to represent your story and likeness authentically.  

Our audience includes

  • Other organizations that work with us
  • Donors (institutions, companies and groups of individual supporters) who support our work by providing funding and other resources. 
  • Media including newspapers, magazines, TV and radio.

Your Rights

  • You have the right to access and update your story.
  • You have the right to change your mind at any time and revoke your consent. If you inform us, we will not use your story in future communications. Please understand that we may not be able to withdraw images and stories already published.
  • If you wish for your story to stop being used, or if you have any questions or comments about how your story is being used, please contact us at:

Email:_________________________________
Phone:_________________________________
Address: _______________________________
_________________________________________
Website: ________________________________

Section 2

Permission

I give permission to the organization to do the following:

_______Interview me
_______Take pictures of my image
_______Record my voice
_______Videotape me

Privacy

I request the following conditions about the use of my image, voice, and name:

_______Obscure my image so as not to reveal my identity
_______Use a pseudonym to protect my identity
_______Mask my voice  to protect my identity

_______Other conditions or considerations (describe below):

_______________________________________________

Signatures

Contributor Signature : _______________________ Date: ________________

Witness Signature: _____________________ Relationship: ___________________

Organization Signature: _____________________ Title: ____________________

Translator Signature: ______________________ Language: _____________________

To download an unbranded copy of this form in MS word that you can customize for your organization, click the button below:

Download MS Word Version