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Baby Buggy Walk in the Park – Sample Photo Release Form

Baby Buggy Walk logo
Baby Buggy Walk Home Section 1: What is the Baby Buggy Walk in the Park? Goals and Objectives Section 2: Getting Started Section 3: Recruiting Sponsors Section 4: Promoting Your Event Section 5: Evaluation and Follow-up Sample Event Checklist Sample Budget Sample Sponsor Letter Sample Evaluation Survey Sample Photo Release form Sample Media Advisory Sample Press Release Campaign Materials
2012 Baby Buggy Walk event image
U.S. Department of Health and Human Services

Office of Minority Health

Authorization, Release, and Clearance

Authorization to Use Photographs and/or Audio-Visual Recordings I hereby grant the Office of Minority Health (OMH),U.S. Department of Health and Human Services (HHS) permission to use, reproduce, or publish my image, likeness, or voice without compensation or any other consideration, in photographs and/or video for purposes of advancing OMH?s mission and publicizing its programs and initiatives and for any other lawful purpose.

I understand that these photographs and audio-visual recordings are the property of OMH and will not be returned. I also understand that these photographs and audio-visual recordings will be in the public domain and OMH may further reproduce, edit, alter, copy, exhibit, publish, or distribute these photographs and audio-visual recordings without further permission.

I waive the right to inspect or approve the finished product, including any written or electronic copy, wherein my image, likeness, or voice appears. In addition, I hereby hold harmless and release and forever discharge OMH and HHS from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I have read this authorization before signing below and I fully understand the contents, meaning, and impact of this authorization.




Printed Name



Signature
Date



_____ OMH MAY use my real name.
_____ OMH MAY NOT use my real name.


If the person signing is a minor, there must be consent by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of ________________________, named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.




Printed Name of Parent/Guardian of Minor Participant



Signature of Parent/Guardian of Minor Participant
Date



Minor Participant(s) Name(s) and Age(s)




Content Last Modified: 7/8/2013 1:16:00 PM
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Office of Minority Health
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