Photograph Consent Waiver- Town of Bancroft

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* 1. Legal Name:

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* 2. Email Address:

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* 3. Phone Number:

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* 4. Please identify, as specifically as possible, where the photograph was taken:

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* 5. Please identify, as specifically as possible, the date that the photograph was taken:

Date / Time

Date

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* 6. If not on public land, do you have the property owner's permission to share the photograph?

Yes

No

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* 7. I declare that I am the original owner of the photograph submitted to the Town of Bancroft's website. I understand and accept that my photograph will be posted on the Town of Bancroft's 'Photo Gallery'. I understand that there will be no payment for the release/use of my photograph and that no royalty, fee, or other compensation shall become payable to me by reason of such use. I understand that my authorization for the Town of Bancroft’s use of the photograph may never be revoked. I agree and declare that no minor children are identifiable in the photograph and that any persons identifiable in the photograph have expressed their consent to my photograph being used by the Town of Bancroft.

Yes

No

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* 8. I agree to allow the Town of Bancroft to add my photograph to their photo library for use in other Town of Bancroft promotional or professional print or digital materials, with the same rights, obligations, and authorizations as above.

Yes

No