authorization & release

Name of Subject *
Name of Subject
Name of Parent/Guardian (if subject is under 18 years of age)
Name of Parent/Guardian (if subject is under 18 years of age)
Address *
Address
Phone *
Phone
By checking this box, I hereby authorize and consent that United Way of Southwest Michigan, a not-for-profit corporation, its legal representatives, successors or assigns, shall have the right to copyright, publish, use, distribute, or assign any and all material submitted by me including, but not limited to, photographic portraits, pictures, images, videotapes and/or sound recordings, any written printed matter, story, or video, in in whole or in part, including my name or other biographical data, in any media whatsoever, now known or hereby created, for the limited purpose of promoting and conducting United Way of Southwest Michigan charitable fundraising or community impact activities. I hereby waive any compensation for such use. *