Photography and/or Video Consent

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please check one: *

YES! I give permission to The League for the Blind & Disabled, Inc. and involved funding organizations to use photographs and/or videos of myself and or my child/children for use in any publication, display or activity that is related to the work or promotion of The League. I understand The League and/or the funding organization will inform me, when possible, prior to directly releasing these photographs to local, regional/state, or national media for publication. I also understand that I may revoke my consent at any time by simply contacting my case coordinator or the Director of Programs & Services, either verbally or in writing.

NO! I do NOT give permission o the League for the Blind & Disabled, Inc. and involved funding organizations to use photography or video of myself and/or my child/children.

Required

First Name *

Last Name *

Email *

Full Name (signature) of individual or consumer *

Name of legally authorized representative (if applicable)

Name (signature) of legally authorized representative (if applicable)

Today's Date *

YYYY

Phone - Include Area Code *

City *

State / Province / Region *

ZIP / Postal Code *

Submit

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.