Media, Social Media and Publicity Release Form

Media, Social Media and Publicity Release Form

(Not the Noble Annual Packet Consent form)
Note: This form is to be completed when you want to provide a media release for your picture.

This is not to be used as an annual consent form.
I hereby agree to allow my photo/information to be used by Noble in the following way(s)(please check all that apply):*

Traditional Media (i.e. TV, newspaper, radio, magazine, etc)Marketing (i.e. brochures, newsletters, videos, displays, etc)Social Media (i.e. website, Facebook, etc)For a Specific Purpose
For this specific purpose**
File/ Picture Upload

Browse Files

Cancelof
I understand that my photo/information may be used for purposes like publicity, education, training, grants, fundraising, marketing collateral and special events promotion. This consent will expire at the closure of services or until revoked in writing, whichever comes first. Revoking this consent will apply to all future uses. It will not apply to past uses for which I gave my consent. I hereby hold Noble and its affiliates harmless from any and all liabilities that might arise from such uses.

Please Note: While we will make every effort to assist in removing your image from social media, we cannot guarantee complete removal. This is due to factors like third-party sharing, reposts by other users & varying platform policies that may limit our ability to fully control or remove all instances of your image.
Individuals Name:*

First NameLast Name
Date*

MonthDayYear
Date
Individual Signature
Guardian Name (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Guardian Signature (if applicable)
Noble - 7701 E. 21st Street, Indianapolis, IN 46219 - www.mynoblelife.org
I hereby agree to allow my photo to be placed in my files for ID/emergency purposes. This consent will remain in effect for one (1) year or until revoked in writing, whichever comes first. Revoking this consent will apply to all future uses. It will not apply to past uses during which I gave my consent for my photo and information to be used for File ID purposes. I hereby hold Noble and its affiliates harmless from any and all liabilities that might arise from such uses.

Annual Consent for File ID
Date

MonthDayYear
Date
Noble Staff Name

First NameLast Name
Noble Staff email:
example@example.com
Noble Staff Signature
Please Select One of the Following:*

Specific Purpose Consent
Please select:

Specific Purpose ConsentAnnual File Consent
I hereby agree to allow my photo to be placed in my files for ID/emergency purposes. This consent will remain in effect for one (1) year or until revoked in writing, whichever comes first. Revoking this consent will apply to all future uses. It will not apply to past uses during which I gave my consent for my photo and information to be used for File ID purposes. I hereby hold Noble and its affiliates harmless from any and all liabilities that might arise from such uses.

YesNo
Should be Empty: