Youth Services

Scholarship

Agent of Change Scholarship Application

Photo Release

Please sign this release form so we can share your photos. If you are a parent / guardian, please sign this release on behalf of your children. Thank you

Photo Release
First
Last

I, give Hempstead Chamber of Commerce permission to use my and my
children’s (if applicable) name, likeness, image, voice, and/or appearance as such may be embodied in
any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of
Hempstead Chamber of Commerce activities. I agree that Hempstead Chamber of Commerce have
complete ownership of such pictures, etc., including the entire copyright, and may use them for any
purpose consistent Hempstead Chamber of Commerce mission. These uses include, but are not limited
to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements,
and any promotional or educational materials in any medium now known or later developed, including the
Internet. I acknowledge that I will not receive any compensation, etc. for the use of such pictures, etc.,
and hereby release Hempstead Chamber of Commerce and its agents and assigns from any and all claims
which arise out of or are in any way connected with such use. I have read and understood this consent and
release.

It is the policy of Hempstead Chamber of Commerce that the use of photographs and videotapes of
persons served, including on the Internet, with or without his/name attached requires informed voluntary
written consent.
Written consent is the completed form “Permission to Use Photograph or Videotape for Public Relations
or Fundraising.” Due to the nature of client confidentiality, no past or current client will be required or
coerced to provide public statements of gratitude to Hempstead Chamber of Commerce. All public
statements are strictly voluntary. In all cases, client confidentiality supersedes any public relations or
fundraising benefits.

 

I hereby grant this organization permission to use my likeness in a photograph in any and
all of its publications, including website entries, without payment or any other consideration.
I understand and agree that these materials will become the property of the Department of Labor
and will not be returned.

I hereby irrevocably authorize this organization to edit, alter, copy, exhibit, publish or
distribute this photo for purposes of publicizing this organization’s programs or for any
other lawful purpose. In addition, I waive the right to inspect or approve the finished product,
including written or electronic copy, wherein my likeness appears. Additionally, I waive any right
to royalties or other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge this organization 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.

Confirmation