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3. 
5. License & Release Form

   I hereby consent to the unrestricted use of my photographic work or picture, including but not limited to, my name and likeness, by the City of Valdez and its agents or contractors for publicity and public relations purposes in all media now in existence, or hereinafter developed. This includes but is not limited to the use of my picture on the Internet, in brochures, and other media. I understand that this release does not restrict whatever rights the City of Valdez has by law.

   In furtherance of this grant for unrestricted and unlimited use by the City of Valdez, I hereby grant the City of Valdez and its agents or contractors a license to release, disseminate, and use my photographic work or picture, including but not limited to, my name and likeness for publicity and public relations purposes in all media now in existence, and hereinafter developed.

   I hereby release and discharge the City of Valdez, its employees, agents, officers, successors, and assigns from any and all claims, damages, causes of action, attorney fees, and costs that now or may later arise out of or in connection with the use of my name, likeness, photograph(s), photographic work, or pictures including but not limited to, any claims for defamation, invasion of privacy, false light or copyright infringement.

   I have read the above and fully understand it. I understand that if I change my mind I must revoke this consent in writing. Revocation does not require the City to stop any current use of my photograph, likeness, or name in media existing at the time of revocation, but only at the next revision date.

7. Description of Photo*
9. Full Name*
11. Address
13. I am 18 years of age or older:*

    1. Yes

    1. No
15. Electronic Signature*

    By checking the "I agree" box, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
16. Date
18. Consent*

    If the person signing is under 18 years of age, the parent or legal guardian must also give consent.

    1. I, the undersigned, being the parent/legal guardian of the person whose name appears above, do hereby consent without reservations to the release and uses described above.
20. Parent or Legal Guardian's Full Name*
22. Parent or Legal Guardian's Address
24. Parent or Legal Guardian's Electronic Signature*

    By checking the "I agree" box, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
25. Date
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

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