Media Release Form

I grant permission to Upper Kirby District Foundation, dba, Levy Park Conservancy (“LPC”) to use my image (photographs and/or video) for use in LPC or agency client publications including, but not limited to, videos, email blasts, recruiting brochures, newsletters, and magazines and to use my image in electronic versions of the same publications or on the LPC website, on the websites of LPC clients, or other electronic forms of media. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to compensation or royalties, if any should exist, arising from or related to the use of the image.

Please check the paragraph below which is applicable to your present situation:

I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below,and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will bedeemed conclusive evidence of a free and knowledgeable acceptance of the terms of this release. Please check it here.

I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be deemed conclusive evidence of a free and knowledgeable acceptance of the terms of this release. Please check it here.

Please fill your name: *

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Please fill in Address: *

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Your Signature *

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Signature of parent or legal guardian (if under 18 years of age) Please click the yellow area and provide your initials here.

Signature Date *

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Media Release Form