Publicity Release

Publicity Release
Please read and complete Northwest Mothers Milk Bank's Publicity Release form.
- I consent to the use of my name, likeness, and any personal statements I may provide to be used by Northwest Mothers Milk Bank (NWMMB) and/or Human Milk Banking Association of North America (HMBANA) in connection with promotional, education, editorial and/or fundraising services and activities.
- I consent and authorize NWMMB and/or HMBANA to use my likeness in a photograph, video, or other digital media, in any and all of NWMMB and/or HMBANA's publications, including but not limited to print or web-based publications. NWMMB and/or HMBANA may copy, edit, enhance, crop, or otherwise alter photo/media in any way.
- I waive the right to review or approve the released materials.
- I understand that I will not receive payment from NWMMB or HMBANA for use of likeness, photographs, or personal statements.
Name*

First NameLast Name
If you are a milk donor, please provide your Donor Number
(if applies)
Phone Number

Area CodePhone Number
Email*
example@example.com
Event (if applies)
Mark all that apply.

Milk DonorMilk RecipientVolunteerInternEvent AttendeeStaff or Board MemberOther
Signature*

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Date

MonthDayYear
Date
Upload Picture (if applies)

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