I hereby agree to a video/audio recording and/or photographic and/or written
documentation of the interview between
_________________________________________ and ____________________________on
_______________________.
I understand that I will receive a personal copy of this interview.
I agree to the following conditions as they pertain to my portion of the interview, unless specifically noted as a restriction:
1) I give my permission for all recordings, photographs, and written records
to be used for educational and scholarly purposes, including publications
and exhibits.
2) When the material is used, proper acknowledgement shall be made of
the interviewee/donor.
3) The material gathered shall be placed in the collections of the Kansas Historical Society, Topeka, Kansas; the Veterans History Project at the Library
of Congress, Washington, D. C.; and the (local institution name and location)
for use by researchers.
4) The Kansas Historical Society may include information about this interview,
portions or all of the transcript and/or excerpts of the interview on their
web site www.kshs.org. I give my permission for this use.
_____yes ______no
If yes, the Kansas Historical Society
_____ may include my address. _____ may not include my address in their database
on their web site.
5) If a researcher wishes to use the information gathered for other than
educational and scholarly purposes, he/she
_____ may do so _____ may not do so without further permission.
Restrictions:
Name (Please print):___________________________________________________
Address ____________________________________________________________
___________________________________________________________________
Phone Number _______________________________________________________
Signature ___________________________________________________________Date _______________
As a participant in the interview described above, I agree to all of the conditions
listed above as they pertain to my portion of the interview, unless noted as
an exception below or on the back.
Name (Please print): ___________________________________________________
Interviewer Signature _________________________________________________Date
_______________