Photo Consent

Histio Awareness Photo Submittal & Release Form

* Indicates required field

Name *

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Last

Email *

Address *

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Photo Consent

Photo Consent for Self *

I AGREE

I, the above named person, hereby grant permission to Liam’s Lighthouse Foundation of Colorado Springs, Colorado, and its representatives, to use the following: photographs and/or digital images of me or my child, whose name is indicated on the signature line below in the upcoming Histio Awareness campaign arranged by Liam’s Lighthouse Foundation to be held in New York City at Rockefeller Center. I understand and agree that said picture might appear on national television, given the opportunity, or be used in printed or electronic publications, Web sites or other electronic communications. I further agree that only my child’s first name may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All prints and digital reproductions shall remain in the possession of Liam’s Lighthouse Foundation.

Consent for Child *

I AGREE Self application. Does not apply.

Child's Name *

First

Last

I, the above named person, parent or Official guardian of (child’s name) in box above (IF NOT FILLED IN THIS FORM WILL NEED TO BE RESUBMITTED),hereby grants permission to Liam’s Lighthouse Foundation of Colorado Springs ,Colorado, and its representatives, to take and use photographs and/or digital images of my child for use in news releases and/or educational materials as follows: printed publications or materials, electronic publications, or Web sites. I agree that my child’s first name may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All prints and digital reproductions shall remain in the possession of Liam’s Lighthouse Foundation.

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Histio Awareness Photo Submittal & Release Form

Photo Consent

Saturday November 3, 2018 | Philadelphia, PA

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