PHOTO CONSENT FORM

I, _____________________________ grant permission to _____________________________

for the use of the photograph(s) or electronic media images as identified below in any

presentation of any and all kind whatsoever. I understand that I may revoke this

authorization at any time by notifying _____________________________ in writing. The

revocation will not affect any actions taken before the receipt of this written

Phone _____________________________ Email ___________________________

Signature _________________________________________ Date _____________________