2024-2025 Image Release Form

Image Release Form
Ohio Conference

1251 E. Dorothy Lane, Dayton OH 45419

www.ohioadventist.org

For value received, I hereby consent and authorize the Ohio Conference of Seventh-day Adventists ("Ohio Conference"), or its assigns, to use my image and/or video and/or the images of my family members who are minors, as listed below, for the purpose of news releases, advertising, publicity, publication or distribution in any manner whatsoever. I further consent to such use in their present form and to any changes, alterations, or additions thereto. I hereby release the Ohio Conference of Seventh-day Adventist from all liability in connection with all such uses.
Date*

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Date
(Please Print Name)*
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Address*

Street Address

Street Address Line 2

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Phone Number*
Email*
example@example.com
Additional Minor Family Members to Whom this Release Applies
Club Name*
Director's Name*
Email
example@example.com
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