CHILD MEDIA RELEASE

For the purpose of promoting the services provided by Maggie’s Wigs 4 Kids of Michigan, I hereby grant the organization and/or entities for whom and with whom Maggie’s Wigs 4 Kids of Michigan is acting, full authorization and absolute right and permission to reproduce, copyright, assign, convey, and/or publish photographs of me, or photographs in which I may be included.

As used in this Release, “photograph” means any photograph or photographic reproduction – still or moving on film or other medium in which I may be identifiable or otherwise appear to be depicted. Please check the following boxes if you agree to Maggie’s Wigs 4 Kids of Michigan using your photograph publically in the following outlets:

Printing/Press Materials

MagazineNewspaper

Digital Media

Social MediaWebsiteElectronic Billboard

I would NOT like my photo to be used in the listed outlets, except in my file,for the sponsor of my wig, and in the look book for other wig recipients toview.

Maggie’s Wigs 4 Kids of Michigan will offer me the opportunity to approve or deny use of any finished product or any advertising copy which may be used in connection with the organization.

I hereby release, discharge and agree to hold harmless Maggie’s Wigs 4 Kids of Michigan.I affirm the statements I have made in connection with the image being produced by Maggie’s Wigs 4 Kids of Michigan are true, correct, and complete.

Signature of parent or guardian:

Print name of parent or guardian:

Address:

City, State, Zip:

Home Phone:

Date

30130 Harper Ave, St. Clair Shores MI, 48082
2 Phone: 586-772-6656 • Fax: 586-772-6674 • www.wigs4kids.org