Authorization to Use Personal Information and Personal Media

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.

For volunteers or trainees, refusal to sign will not affect your status.

Authorization form

• Volunteers/Returned Volunteers: Select country of service
• All others: Select country of residence

Enter email address (preferred) or phone number:

Enter numbers only

Authorization and agreement:

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)