I hereby grant permission to the Minnesota Coalition Against Sexual Assault to use, reproduce, and/or publish videos that pertain to me—including my image, likeness, and/or voice without compensation. I understand my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears.

By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in public educational settings.

This release applies to photographic, audio, or video recordings collected as part of Demand the Change for Children on Saturday, March 23, 2013.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

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* 1. I permit the Minnesota Coalition Against Sexual Assault to share my video message with policy makers.

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* 2. I permit the Minnesota Coalition Against Sexual Assault to project my video message to inspire others.

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* 3. I permit the Minnesota Coalition Against Sexual Assault to use my video message for raising awareness of child sexual abuse. I may revoke my permission at any time by notifying Minnesota Coalition Against Sexual Assault of my wish to do so.

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* 4. First Name:

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* 5. Last Name:

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* 6. Mailing Address:

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* 7. City:

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* 8. State:

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* 9. Zip:

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* 10. E-mail Address:

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* 11. Signature:

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* 12. Date:

If the participant is under the age of 19, then the signature of that participant’s parent or legal guardian is also required.

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* 13. Signature:

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* 14. Date:

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