Say cheese! Thanks for letting us capture your smile. This form gives us permission to use any photos or videos with you in them. Ready? Let’s go! Participant Name(Required) First name Last name Phone Number(Required)Email Address(Required) Digital Signature(Required)Is the participant under 18 years old? Yes No Parent or Legal Guardian NameA parent or legal guardian name and digital signature is required for individuals under age 18. First name Last name Parent or Legal Guardian Digital Signature(Required)Acknowledgments(Required) I consent to the use of my photo and video given the acknowlegments below.Grant: For consideration which I acknowledge, I irrevocably grant Dupaco Community Credit Union (Dupaco) and Dupaco’s assigns, licensees and successors the right to use my image and name in all forms and media including composite or modified representations for all purposes, including advertisement, trade or any commercial purpose throughout the world in perpetuity. I waive the right to inspect or approve versions of my image used for publication or the written copy that may be used in connection with the images. Release: I release Dupaco’s assigns, licensees and successors from any claims that may arise regarding the use of my image including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright. Company is permitted, although not obligated, to include my name as a credit in connection with the image. Date MM slash DD slash YYYY