Lifeline of Ohio Photo/Media Authorization Form

I irrevocably authorize Lifeline of Ohio to use my name (and my family if applicable), written statements/quotes, photographs and videos to promote organ, eye and tissue donation via digital, television, radio, newspapers, magazines, social media, websites, educational materials/displays, community presentations, billboards or other means. I hereby release Lifeline of Ohio from claims or liabilities that may arise from these uses. I acknowledge that this authorization is voluntary and without obligation from Lifeline of Ohio.
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
Format: (000) 000-0000.
Email address
example@example.com
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If the person who signed above is under the age of 18, a parent/guardian must also sign and state their relationship.
Parent/guardian signature (if applicable)
Relationship
Should be Empty: