Donate Life NW Information Release Form

1. Name & contact information of person photographed or recorded

First Name

Last Name

Age (if a minor)

Street Address

City

Postal Code

State/Province

Phone Number

In consideration of public education about organ and tissue donation, I give to Donate Life Northwest, its nominees, agents, and assigns unlimited permission to use, publish, and republish for purpose of advertising, trade, or any other lawful use in furtherance of the mission of Donate Life Northwest, information about me and reproduction of my likeness (photographs or otherwise) and my voice related to any affiliation with Donate Life Northwest, with or without my name.

Sign above

Today's date:

2. Consent of parent or legal guardian if above individual is a minor

Name of parent / legal guardian

First

Middle

Last

Suffix

Relationship to the minor named above

3. Event information:

Producer, writer, or photographer

Assignment and Location

If unknown, leave blank.

Stories of Hope

— Rick Hulcher

Donate Life NW Information Release Form