Pathfinder Image Release

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 with all such uses.
Dated this:

MonthDayYear
Date
Signature:
PERSONAL INFORMATION
First Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Church of Attendance
Please add name of church you attend
Director's Name
Director's Email
example@example.com
ADDITIONAL MINOR FAMILY MEMBERS TO WHOM THIS RELEASE APPLIES
Should be Empty:

IMAGE RELEASE FORM