Media Release Form
Please complete this form to share your picture, video or audio during your participation with Community Initiatives for Collective Impact (CI4CI) and its affiliates (Hlub Hmong Center, People's Garden & Pantry, Compass, Project Grow, Project Count, and others)

Please contact us if you have any questions, need more information or to send us your release form.
Community Initiatives for Collective Impact
936 W. 18th St, Merced, CA 94340, 209-769-3231, support@ci4ci.org
A printable copy of this form can be found here: https://tinyurl.com/mediareleaseform2
Email address *
For what event, activity or other situation are you sharing your picture, audio, video, or other media?
Your answer
Please read the following and then provide your information.
I understand that the photograph(s) or video or audio recording(s) or other media taken of me by agents, employees or representatives of the Community Initiatives for Collective Impact (hereinafter “CI4CI”) shall be used in connection with CI4CI’s services and programs to the general public.

I hereby irrevocably authorize CI4CI to copy, exhibit, publish or distribute any and all such images and audio of me or wherein I appear, including composite or artistic forms and media, for purposes of supporting CI4CI goals and mission or for any other lawful purpose. In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my likeness appears.

I hereby hold harmless and release and forever discharge CI4CI 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.
Are you completing this as a parent or guardian of a minor (under 18 years old)? *
Required
If YES, please provide the minor’s first and last name:
Your answer
Your printed name: *
Your answer
Your signature: (If you are signing this by phone, email, or website, please print your name as in your signature.) *
Your answer
Date: 05/02/2020
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Your answer
Email address:
Your answer
Mailing address:
Your answer
Are you under 18 years old? *
Required
If “YES”, please provide the parent/guardian consent here.
Please have the parent/guardian provide this information here: “The parent and guardian named here certifies that they are the parent of guardian of the minor requesting approval (named above) and gives their consent without reservation to the foregoing on behalf of this person.”
Parent/guardian printed name:
Your answer
Parent/guardian signature: (If you are signing this by phone, email, or website, please print your name as in your signature.)
Your answer
Parent/guardian phone:
Your answer
Parent/guardian email address:
Your answer
Parent/guardian mailing address:
Your answer
Date:
MM
/
DD
/
YYYY
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