Photo/Video Release Form

Authorization to use Photographs and/or Audio-Visual

Name

First Name

Last Name

Email Address

I hereby authorize the Nevada Sagebrush Chapter of the National Society Daughters of the American Revolution (NSDAR), to use, reproduce, and/or publish photographs and/or video that may pertain to me and/or my minor-age child

including image, likeness and/or voice without compensation. I understand that this material may possibly be used in various publications, public affairs releases, recruitment materials, broadcast public service announcements (PSAs) or for other related endeavors. This material may also appear on the NSDAR's Internet Web Page. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, the NSDAR or chapter affiliates may publish materials, use the name, photograph, and reference me and/or my minor-age child as deemed appropriate in order to promote/publicize the NSDAR goals of historic preservation, education and patriotism. Description of Material (Photos/Audio-Visual):

Electronic Signature

First and Last Name

Agreement

I understand that checking this box constitutes my electronic signature as a legal signature in AGREEANCE to this Photo/Video Release Form, and that the Nevada Sagebrush Chapter IS authorized to use Photographs and/or Audio-Visual material related to me. I also understand that checking this box constitutes the Submission Date of this form as the date of my agreeance.