AUTHORIZATION AND RELEASE

AUTHORIZATION AND RELEASE
PAINTINGS FOR PEDIATRICS, INC. (the "Foundation") is hereby authorized to use the undersigned's photograph, appearance in a video, likeness, name, voice, words, and story (collectively "Disclosed Information) in social media, websites, television, radio, film, newspaper, magazines, and any other media, in any form, for the purposes of promotion

and documentation of the Foundation. The Foundation is further authorized to use the

Disclosed Information for fundraising or for any other purpose the Foundation deems fit to further the purpose of the Foundation. Use of the Disclosed Information shall be royalty
Painters NAME*
ADDRESS*
CITY*
STATE*
ZIP*
AGE*
PHONE NUMBER*
NAME OF PARENT/GUARDIAN IF MINOR
ADDRESS IF DIFFERENT THAN ABOVE
CITY
STATE
ZIP
PHONE NUMBER IF DIFFERENT THAN ABOVE
E MAIL*
example@example.com
SIGNATURE OF PARTICIPANT

Clear
DATE

MonthDayYear
Date
SIGNATURE OF PARENT/LEGAL GUARDIAN (IF PARTICIPANT IS UNDER AGE 18)

Clear
DATE

MonthDayYear
Date
SIGNATURE OF PARENT/LEGAL GUARDIAN
(IF PARTICIPANT IS UNDER AGE 18)
Should be Empty: