I hereby consent to the Service Employees International Union, and its locals and affiliates, (the “Union”) using and publishing the information I have provided to the Union, including my name, photograph, statement, video, and any other information I have given to the Union. I release the Union from all liability and any claims I may have arising out of the use and publication of this material.

By submitting this form, I confirm that I am at least 18 years of age and that all information in the material that I have provided to the Union is true and accurate, to the best of my knowledge.