Speaker Release Form


This form must be completed by the person who is being interviewed. If this is not you, please forward this page to the person who needs to complete it.
This form is provided to you as a speaker in a production created by Mission Based Media Ltd. Thank you for agreeing to share your perspective, experience and knowledge with our audiences.
Please review and complete this form, apply your electronic signature, and click the button at the bottom of the page. A copy of the document will be emailed to you on completion.
Our mission is to share experiences and knowledge to help inform, educate and inspire people to lead healthier, happier lives. Thank you again for your participation!
Kind regards,
Dan Kendall
Founder, CEO
Mission Based Media Ltd

This Speaker Release Form (“Release”) ensures the publisher, Mission Based Media Ltd, (“MBM”), which operates its primary place of business at Unit 6 Heritage Business Centre, Derby Road, Belper Derbyshire DE56 1SW, UK, has the necessary permissions to share my images, name, likeness and audio and visual recordings on its various media platforms around the world.
By applying my signature below, I agree to be interviewed and grant MBM the right to record, stream, film and photograph my interview conducted online or in person.
I agree that MBM has complete ownership of materials generated as part of my participation in this interview, including the entire copyright, and may use them for any purpose related to this organization.
I also grant MBM the non-exclusive perpetual worldwide right to use my name, likeness, image, voice, biographic information and/or appearance as such may be embodied in any testimonials, pictures, photos, video and/or audio recordings, digital images, and the like, taken or made on behalf of MBM activities.
These uses include, but are not limited to podcasts, illustrations, bulletins, exhibitions, videos, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the internet.
I acknowledge that I will not receive any monetary compensation and hereby release MBM and its agents, successors and assigns from any and all claims which arise out of or are in any way connected with such use.
I understand that I can opt out within 10 business days by notifying MBM at [email protected] Execution of this Release does not obligate MBM to publish the materials.
By completing this Release, I acknowledge that I have read and understood these conditions.


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Signature Certificate
Document name: Speaker Release Form #v.22J05
lock iconUnique Document ID: cb9714788396e78914466c257fb673fab973bc61
Timestamp Audit
2022-10-06 10:35:42 GMTSpeaker Release Form #v.22J05 Uploaded by Dan Kendall - [email protected] IP