FSRI Performance Release

  • Performance & Media Release

  • FSRI Affiliation*

  • You are filling this form as an FSRI {fsriAffiliation}.

    We ask that you complete this form using your FSRI employee email address (last name, first 2 letter of first name@familyserviceri.org). If you are unsure of your hire date, check with HR or select "I am not sure".

  • Employee Hire Date
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  • Please select the option that most applies to you.

  • To add additional names, use the (+) symbol to the right of the field below, please be sure to enter first and last name of all minors. 

  • Date
     / /

  • Family Service of Rhode Island
    Public Performance Release 

    I {name}, hereby grant Family Service of Rhode Island permission to use my (or the named minor below for whom I am the legal guardian) name, likeness in a photograph, video, or voice recording, in any and all of its publications, including website entries, public relations, promotional, development or related activities without payment or any other consideration. I understand and agree that these materials will become the property of Family Service of Rhode Island and will not be returned.

    I hereby irrevocably authorize Family Service of Rhode Island to edit, alter, copy, exhibit, publish or distribute this photo for purposes of publicizing Family Service of Rhode Island’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

    I hereby hold harmless and release and forever discharge Family Service of Rhode Island 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 because of this authorization.

    I understand that such participation is voluntary and I (and/or the named minor for whom I am the legal guardian) hereby note that I (we are) not being required by Family Service of Rhode Island, Lucy’s Hearth or its agents to make public statements of gratitude or to be identified as a consumer in any of the aforementioned activities.

    I have read this release before signing and I fully understand the contents, meaning, and impact of this release.

    STATEMENT OF UNDERSTANDING

    You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Family Serivce of Rhode Island. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your release shall be legally binding and such transaction shall be considered authorized by you.

    {name} {date}
    {nameOf}  
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