Publicity Permission Form

Individuals over the age of 18 and who are self-guardians may sign for themselves; anyone under 18 or under guardianship must have the release signed by their parent or legal guardian.

I hereby grant permission to Starbridge to use any and all of the following:(Required)

photographs of my child/dependent/self

name of my child/dependent/self

story of my child/dependent/self

in any official publicity pieces consistent with Starbridge’s mission. Publicity pieces include (but are not limited to) print or digital publications, news releases, videos, brochures, promotional materials, and web use. I understand that signing this release does not guarantee publication of selected items and that I am not being compensated for my participation. I understand that participation in a publicity project – or refusal to participate – will not affect or harm any services my child/dependent/self receives from Starbridge now or in the future. * This form is valid for up to one year from date of signature.*

Name of person in publicity piece(Required)

If this person is under 18 or under guardianship, name of parent or guardian of individual

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Email(Required)

Signature(Required)

Date

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