PUBLICATION AUTHORIZATION

Authorization to use a story form

I, the undersigned)………………………………………………………………………………….

Address : ………………………………………………………………………………….……

Expressly authorizes (name of the structure) ………………………………………………. ……

- to reproduce in written form the oral story that I proposed as part of a workshop around the role model which took place on (date) .............. .......... at (place) ................................

- to distribute this story within the portrait gallery of the “Change of View” project, on the website provided for this purpose

- translate my story into Spanish and English

I acknowledge that I will not be entitled to any compensation for the use of my story.

(Check the box of your choice)

◇ My first name must appear on the text as the author of the text

Or

◇ I want my first name not to be mentioned but to be changed so that I can keep my anomymat.

Done at ……………………………………………………., On …………………………… ..….… ..

Signature (mention read and approved)