School Photo Release Form

WVCRN Authorization of Release of Information

For Promotional and Media Purposes
West Virginia Collegiate Recovery Network (WVCRN) respectfully requests your permission to use your image and/or information in connection with our program's promotional efforts. The image and/or information will be used or disclosed by the WVCRN for news stories, articles, journal publications, brochures, newsletters, advertisements, videos, websites, social media and other promotional purposes

With this, we seek for your consent in allowing us to publish photos which may involve your photo or information to the said platforms.

Please provide your agreed upon response by selecting your choice below and submitting this form:
I allow the reproduction and publication of my photographsI do not allow the reproduction and publication of my photographsI allow the reproduction and publication of my first and last nameI do not allow the reproduction and publication of my first and last nameI allow the use of my first name onlyI do not allow the use of my nameI allow the name of the college I attend to be publishedI do not allow the name of the college I attend to be published.
What college/university do you attend?
Name:
First Last
Email
example@example.com
Contact Number

Area CodePhone Number
Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

WVCRN Authorization of Release of Information