Image Waiver

The Holley Institute

Image Waiver
Authorization and Waiver for taking and presenting images of and/or information from/about a person at the Holley Institute's Carls Family Village
I, the undersigned, do with this authorize a representative of the Holley Institute's Carls Family Village for print media (newspaper, magazine, etc.) or electronic media (social media, television, radio, etc.) to photograph, film, audio, or videotape and interview the following person for possible presentation in public:

This authorization is intended to release The Holley Institute's Carls Family Village from all liabilities of any nature concerning such use of images or interviews thereof.
What program are you registered for:*

Family Literacy WeekendASL Immersion WeekendFamily Week OneFamily Week TwoFamily Week ThreeTeen WeekASL Immersion WeekJesus Deaf CrewVolunteer WeekStaffSt. Nicholas Christmas EventOther
Name of person signing*

First NameLast Name
Name of participant #1

First NameLast Name
Name of participant #2

First NameLast Name
Name of participant #3

First NameLast Name
Name of participant #4

First NameLast Name
Name of participant #5

First NameLast Name
Name of participant #6

First NameLast Name
Name of participant #7

First NameLast Name
Name of participant #8

First NameLast Name
Check the participants here if you would not like pictures of them (optional)

Participant #1Participant #2Participant #3Participant #4Participant #5Participant #6Participant #7Participant #8
I agree to have the pictures taken of the participants listed above.*

YesNo
By signing here, you are stating that you agree to the Image Waiver form (above). You agree your electronic signature is the legal equivalent of your manual signature on this agreement. *

Clear
Should be Empty:

The Holley Institute

Authorization and Waiver for taking and presenting images of and/or information from/about a person at the Holley Institute's Carls Family Village