Participant Media Release Form

I, the undersigned, do hereby grant or deny permission to Sokaogon Chippewa TrANS program to use the name, image or life details of:

I, the undersigned, do hereby grant or deny permission to Sokaogon Chippewa TrANS program to use the name, image or life details of:

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Grant

Deny

Restrictions:

Do not use the last name of the person listed above

Use picture and story only with a pseudonym

Only use picture without name

Such use includes the display, distribution, publication, transmission, or otherwise use of names, photographs, images, testimonials, quotes, video, and audio taken for use in materials that include, but may be limited to, printed materials such as annual reports, brochures, newsletters, and digital images such as those on the Sokaogon Chippewa Community website, social media sites, and powerpoint presentations, without further notifying me, and without monetary compensation.

I hereby waive, release, and forever discharge the Sokaogon Chippewa Community, sponsors, promoters, board members, and all other persons associated with the Sokaogon Chippewa Community, events, or media recordings, from any and all claims for the damages to person or property.

I have read and understand the following statements about my rights:

I may revoke this authorization at any time by notifying the Sokaogon Chippewa Community in writing, but the revocation will not have any effect on any actions the SCC took before it received the revocation.
This release remains in effect indefinitely unless revoked by me.

Signature

Date:

Verification

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