Photo Release -

Name *

First

Last

Child's Name if a minor

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

I agree *

I hereby authorize and grant permission to Paws Giving Independence to reproduce my first name (or my child) and/or photographic image, and/or any video footage of me, provided such photograph or video shall have been taken by Paws Giving Independence, or obtained by them either from me or with my consent. I agree that such reproduction may be edited as desired. I consent to the use of my first name, photographic image, video footage and biographical material about me in any promotional materials. I represent that I have the right to enter into the Agreement and that my rights I have granted in this Agreement will not violate any commitment or understanding I have with any other person or entity. I agree to indemnify and hold harmless Paws Giving Independence, its officers, members, executors, assigns, and/or any other parties or entities employed by it in relation to the usage of the aforesaid information against all claims, losses, expenses and liabilities of every kind including reasonable attorney’s fees, arising out of the inaccuracy or breach of any provision of this Agreement. I expressly release Paws Giving Independence, its officers, members, executors, assigns, and/or said other parties or entities from any and all claims arising out of the use of my first name and/or photographic image and/or video footage. This Agreement represents the entire understanding of the parties and shall be permanent unless revoked by me in writing. Should I wish to revoke this agreement, I may do so by writing to Paws Giving Independence at PO BOX 9572, Peoria, IL 61612-9572.

Photos to use

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