Materials Release Form

I hereby give and grant permission for the described versions of my storytelling materials to be used by the Roosevelt High School Oral History Program for such scholarly and educational purposes as shall be determined under the discretion of the Director of the aforementioned Program. As such, full literary rights to these materials are granted to the program for scholarly pursuits.

Project Title:

Description of Materials:

Title(s) (if any):


Medium:

_____ Transcript   _____ Sound Recording

_____ Video Recording    _____ Illustration

_____ Other (Describe):

Signed: ___________________________________

Permanent Address and Phone of Signer: