Photo/Video Waiver Release Form

Photo/Video Waiver Release Form
I give permission for my name, likeness, image, and voice (or that of my child) to be used by United Way of South Central Indiana, a partner agency, or a community initiative for a variety of purposes, including, but not limited to, video, newsletter, print, website, and other communication materials. I waive any rights of compensation or ownership.

I waive my right to inspect or approve the photographs/videos by which my likeness appears.

I hereby hold harmless, release, and forever discharge United Way of South Central Indiana from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
Age of Participant*

Participant is 18-years-old or olderParticipant is a minor (under 18-years-old) and represented by a parent/guardian
I declare true my age of consent, and in case I am under the age of such consenting age, I have obtained the required consent from my parents/guardians as evidenced by the signatures below:
Name of Participant *

First NameLast Name
Name of Participants Parent/Guardian

First NameLast Name
Signature*

Clear
Date SIgned*

MonthDayYear
Date
Should be Empty: