1251 E Dorothy Ln
Dayton OH 45419
(937) 741-0236
Website: www.ohioadventist.org
IMAGE RELEASE FORM
For value received, I hereby consent and authorize the Ohio Conference of Seventh-day Adventists ("Ohio Conference"), or its assigns, to use my image and/or video and/or the images of my family members who are minors, as listed below, for the purpose of news releases, advertising, publicity, publication or distribution in any manner whatsoever. I further consent to such use in their present form and to any changes, alterations, or additions thereto. I hereby release the Ohio Conference of Seventh-day Adventist from all liability in connection with all such uses.
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Day
Year
Date
Signature:
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PERSONAL INFORMATION
First Name
*
Last Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Zip
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Church of Attendance
*
Church/Group Leader's Name
*
Church/Group Leader's Email
*
example@example.com
ADDITIONAL MINOR FAMILY MEMBERS TO WHOM THIS RELEASE APPLIES
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