United States Department of State

Bureau of Educational and Cultural Affairs

Washington, D.C. 20522

Fulbright Program

PARTICIPANT CONSENT FORM

I, _________________________________________,

Participant Printed Name (First, Middle, Last)

in connection with my participation in the United States Department of State (“DOS”)-sponsored

Fulbright Program (“the Program”), hereby consent to and authorize DOS, my grantee organization and
my host institution to exhibit, reproduce, distribute, and/or display my:

(Please check all that apply)

 Name
 Likeness or Image
 Words and/or Written Materials

in all media and/or technology developed in connection with the Program.

I also understand that journalists and/or other members of the media may be present at official Fulbright
events and activities. Upon request:

 Yes, I would be willing to be interviewed about my Fulbright experiences

 No, I would not be willing to be interviewed about my Fulbright experiences

ACCEPTED AND AGREED TO BY: *

______________________________________ _______________
Participant Signature Date

______________________________________
Participant Home Country

I DECLINE TO CONSENT: *

______________________________________ ________________
Participant Signature Date

_______________________________________
Participant Home Country

* I understand that I am free to change my mind during the course of the Program, in which case I will
sign a new PARTICIPANT CONSENT FORM, and the later-dated FORM will govern.