Media Release

Media Release
MEDIA NOTICE (required)
PERMISSION: I further give permission for images or media to be used for the following purposes (optional: select all that apply)
*Any images or media used for marketing purposes will be intentionally vague and will not contain names or any sensitive or personal information. Permission to use images or media may be revoked at any time by sending an email to valori@partnershipforrenewal.com.
Name

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: