Personal Media Authorization

This Authorization (this “Authorization”) to Use Personal Information and Personal Media allows the Peace Corps to use your name, biographical information, and likeness (collectively, Personal Information), and photos, videos, stories, blogs, music, and other media (including social media) you have submitted (collectively, Personal Media) for any purpose authorized under the Peace Corps Act. This could include posting photos, videos, and stories of you on the Peace Corps website and social media channels, in Peace Corps’ print and digital publications as well as other publications, and press releases and other public statements.

You are not required to agree to this Authorization. Please see the Privacy Act Statement at the end of this form.

First name

Last name

Country

Volunteers/RPCVs: Select country of service.
All others: Select country of residence.

Enter email address (preferred) or phone number:

Email address

Phone number

Enter numeric characters only.

Authorization and agreement

I grant the Peace Corps a world-wide, royalty-free, nonexclusive, license to use, reproduce, distribute, display, perform, prepare derivative works of, and publish my Personal Information and Personal Media for any purpose authorized by the Peace Corps Act. I also acknowledge that the Peace Corps may choose not to use my Personal Information and Personal Media at this time, but may do so at the agency’s discretion at a later date. I affirm I own or have obtained the necessary licenses, rights, consents, authorizations, and permissions for the Personal Media I have submitted, including all authorizations and consents from the subject(s) of the Personal Media that I have submitted to the Peace Corps. These consents and authorizations include those of parents/guardians of children who are the subject(s) of the Personal Media.

I acknowledge that I will receive no compensation from the Peace Corps in consideration of this Authorization or the use of the Personal Personal Information and Personal Media Media pursuant to this Authorization. I understand that by signing or by checking the “Agreed to and Accepted” box above, I am agreeing to and accepting the terms of this Authorization which will serve as my legally valid signature and has the full force and effect of a hand written signature. I understand that I may revoke this Authorization at any time in writing to the Peace Corps.

If you have questions regarding this task, please contact pressoffice@peacecorps.gov.

I agree to and accept the authorization.

I would like to submit media now.

Privacy Act Statement

The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974 (5 U.S.C. 552a) to advise you of the following information regarding this form. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

Authority: This form is authorized by the Peace Corps Act of 1961, as amended, 22 U.S.C § 34. 2501(a) et seq.

Purpose: The information you provide will authorize the Peace Corps to use your name and submitted Personal Information as defined in the form above.

Routine Uses: Use of the Personal information collected based on this form is restricted to the purposes cited in this privacy statement or unless the disclosure is otherwise permitted under the provisions of the Privacy Act of 1974, 5 U.S.C. 552a, and the agency’s privacy policy. The Personal Information you provide may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses A through M, as defined in the Peace Corps' System of Records PC-17 and PC-21. For information on Routine Uses A through M, please click on the link to the Peace Corps Privacy webpage.

Disclosure: The completion of this form is voluntary. The agency is committed to ensuring that any Personal Information received is safeguarded against unauthorized disclosure. However, failure to submit this form will result in the Peace Corps’ inability to use your Personal Information and Personal media (as defined in the form above).

PC-2064 (Rev. March 2023)

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