Photo/Video/Story Release Form

1
Your Name* This field is required.
First Name
Last Name
2
Are you 18 or older?* This field is required.A parent or guardian must fill out this form if you are under 18.
YESNO
3
Today's Date* This field is required.
Date
Year
Month
Day
4
Who are you completing this form for?* This field is required.
Myself
My Child
My Ward
5
Your Child or Ward's Name* This field is required.
First Name
Last Name
6
Parent/Guardian Confirmation* This field is required.
7
Mailing AddressOptional. MOFC may send a thank you card in the mail for sharing your story.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Phone NumberOptional. MOFC may call you if we need additional information.
Please enter a valid phone number.
9
EmailOptional. Enter your email to receive a confirmation and copy of this form.
example@example.com
10
MOFC needs a clear photo of your face to keep with your release form. Do you want to take a new photo or upload one from your device?* This field is required.
Take a Photo
Upload From My Device
11
Please upload a clear photo of your face. If you are signing this for someone else (such as a child), upload a photo of them.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Please take a clear photo of your face. If you are signing this for someone else (such as a child), take a photo of them.* This field is required.This photo will only be used to help MOFC verify your consent for photo/video/story use.
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14
If there are things you do not want your materials used for, list those here.
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Large
Normal
Small
Ok
Ok
15
Terms and Conditions* This field is required.By checking the box below, you certify that you have read and accept MOFC's terms and conditions. I authorize Mid-Ohio Food Collective and its authorized partners to publish, re-publish, and edit as needed photographs/video/audio of me and use my statement/story for hunger relief-related purposes. I understand those items may be used for fundraising and advertising, in written publications, on websites, in broadcasts, and/or on social media. If there are specific uses for my provided materials that I do not authorize, I have listed those on the previous page. I acknowledge the items covered by this release belong to MOFC. I understand that MOFC will make reasonable efforts to allow me to review communications that use my information/story, but I acknowledge that may not be possible and waive the right to inspect or approve final products that include materials covered by this release. I certify that I am taking part voluntarily and without expectation of payment or any other consideration. I understand that I am not required to participate in such activities in order to receive food assistance. I release and forever discharge MOFC, its trustees, contractors, employees, partners, affiliates, and any third parties involved in the creation or publication of materials from liability for any claims or legal action asserted by me, my heirs, successors, assigns, personal representatives, or any third party in connection with my participation. I certify that I am at least 18 years of age and competent to contract in my own name. If I am signing this for a minor, ward, or person in guardianship, I certify that I am that person’s legal guardian and can contract on their behalf. I understand the contents, meaning, and impact of this release.
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Signature* This field is required.
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