Media Release Form

I,

Grant permission to MTAC WLA to use My image (photos or videography) in media publications including but not limited to videos, email blasts, youtube videos (Private), newsletters and/or our MTAC WLA branch website. All shared media will be used for educational programs of this branch and the overseeing MTAC state association, and for the promotion of the educational programs of this branch and the MTAC state association. I hereby waive any right to inspect or approve finished photos and videos that may be used in conjunction with them now or in the future, whether that use is known or unknown to me.

Please initial the applicable paragraph below:

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

I,

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

Participant’s Name (required)

Date (required)

Address (required)