Safe Routes to School National Partnership …

                Safe Routes to School National Partnership
                PHOTO WAIVER



Requested by: Safe Routes to School National Partnership

Date: ______________


I hereby irrevocably consent to and authorize the use and reproduction by the Safe Routes to
School National Partnership (SRTSNP), or anyone authorized by them, of any and all
photographs which have been taken of me and submitted to the SRTSNP. The photographs may
be used for any purpose authorized by the SRTSNP, including but not limited to: web site use,
editorial publication, catalog and advertising use.


I am over 18 years of age.    Yes ________ No __________

Model's Legal Name ___________________________________________________

Address____________________________________________________________

__________________________________________________________________

Phone number _____________ Email address________________________________

Signature ________________________________________ Date ______________


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If the model is under 18 years of age, consent must be given by a parent or legal guardian as
follows:

I hereby certify that I am the parent or legal guardian of

___________________________________

I hereby give my consent without reservations to the foregoing on behalf of the model listed
above.

Name __________________________________

Relationship ______________________________

Signature ________________________________________ Date ______________