By submitting this application, I certify that all information provided throughout the entire scholarship application is true, complete, and accurate to the best of my knowledge. I understand that any false, misleading, or omitted information will result in an immediate disqualification from consideration for the GoodwillSR Round Up Scholarship.

I,___________________,being either of legal age to consent or the legal parent or guardian of ______________________, a minor child or person unable to consent on his or her behalf, hereinafter the (“other featured individual"), hereby grant to Goodwill Industries of the Southern Rivers, Inc. the right and permission to use the following collectively referred to as “tangible and intangible items" for any lawful, non-commercial purpose, and in all media without payment or any other consideration:

• Pictures
• Negatives
• Reproductions and copies of original pictures
• Negatives or recordings of me or the other featured individual
• Any recordings that may be made of my or the other featured individual’s voice or likeness
• Any written words or stories supplied by me or the other featured individual or written about me or the other featured individual

In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.

I hereby acknowledge that Goodwill Industries of the Southern Rivers, Inc. may grant the same permissions as outlined in this Consent and Release Form to Goodwill Industries International, Inc. (“GII”) under the same terms and conditions.

This consent and release form shall remain in effect for a period of five years, unless revoked. I understand that I may revoke this consent by submitting a written request to Communication Services, Goodwill Industries of the Southern Rivers, 2601 Cross Country Drive, Building A, Columbus, GA 31906. I understand that, if I revoke this consent, my revocation will not have any effect on actions already taken by Goodwill Industries of the Southern Rivers and/or Goodwill Industries International, Inc. in reliance on my consent.

By typing or electronically signing my name below, I certify that I have read and understand this consent and release form. I have been allowed to have my questions answered, and I have been informed that Goodwill Industries of the Southern Rivers, Inc. must give me a copy of this document once it is signed. I agree and understand by typing my name on the signature line below, which serves as the legal equivalent of my manual or handwritten signature.