Volunteer Information

PERMISSION FOR RELEASE OF PHOTOGRAPHS/VIDEO IMAGES - 115 CMR 5.04(2)

* Required Fields

Section I. Personal Information

Individual's First Name

Individual's Last Name

Address

City

State/Province

Zip/Postal Code

Date of Birth
(mm/dd/yyyy)

Section II. Permission to Use Images

Check Box A. if you wish to give Venture Community Services ongoing permission to use any images of you.

Check Box B. if you only wish to give Venture Community Services permission to use one or more specific images of you (and identify the images by digital description/number e.g. JPEG, GIF, PNG, or attach to this form).

A. I hereby provide my permission to Venture to use any photographic image(s) and/or video(s) of me for the following purposes:

B. I hereby provide my permission to Venture to use these specific photographic image(s) and/or video(s) of me identify here or attach to this form for the following purposes:

Please check all that apply:

Brochures or Pamphlets

Photographic or Video Presentations for Public Display

Photographic or Video Presentations with Personal Information for Public Display

Posting to Venture website and/or social media accounts (e.g. Facebook, Twitter, Instagram, etc) Note: social media posts may include personal information identifying me by name. I acknowlege that images/videos posted on the internet can be viewed and dowloaded by others and that social media posts may be shared by other accounts once posted by Venture and I hereby consent tot he same.

By selection A. I am providing my permission for the ongoing use or disclosure of photographs, and images taken of me (or the individual for whom I am guardian) and that Venture does not have to obtain my permission for additional uses of my image(s) and/or information that I have authorized above during the term of this Permission for Release.

Other (specify below)

Additional Information

INSTRUCTIONS:

This form must be completed in full.

Ensure that the expiration date or event listed on page 2 is practical.
Distribution of copies: Original to Venture; copy to individual, guardian, or other legally authorized person
Please return to: [email protected] or mail to attention Kerrie Mason, 1 Picker Rd, Sturbridge, MA 01566