Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHOTOGRAPHING OF SELF ADVOCATES *

Occasionally pictures of self advocates are taken during SNAP activities. These are used for informational displays about our services to the community and for publicity purposes. They may be incorporated into information which will be provided to the United Way and shown to service organizations in fund raising efforts. There may be times when the photos are published in the SNAP newsletter or the local newspaper. Before use of photos of individuals it is necessary that we have a release signed by the self advocate or his/her parent or guardian on file. Please complete the release for this purpose.

I give my permission for photos of this self advocate to be used for purposes outlined above.

I do not wish to have a photo of this self advocate used for any purpose.