Media/Photo Release Form

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First Name

Last Name

Street Address

Include Apartment or Unit Number separated by a comma

City

State

Postal Code

Country

Consent to media/photo release

By checking this box, I give consent on behalf of myself and/or my dependents to Community Action Network (CAN) to use my dependents' or my name, photograph, portrait, and any likeness in any media form and type of publication, including newspaper articles, annual reports, newsletters, and social media. I grant Community Action Network (CAN) any and all rights to said use without compensation.

I would like to exempt the following members of my household (including myself, if desired) from media/photo release permission (please use first and last names of household members you do NOT want to participate in the media/photo release)

You will be asked to submit an E-Signature on the following page.

Backend Processes. *Do Not Edit*

Director Email

Known User?

Account Name

Contact Information