Authorization and Release for Minor

Authorization and Release for Minor

I, ______parent or legal guardian for ______(“my child”), hereby authorize U.S. Representative Larry Bucshon (the “Member”) to use my child’s voice, portrait, picture, color or black and white photograph, audiovisual or other reproduction of him/her (collectively my child’s “Image”) for any purpose relating to the official duties of the Member (“the Work”). I understand that the Member may use the Work in other media, or other technologies for worldwide distribution, and I grant my authorization for such use. Finally, I authorize the Member to use my child’s Image to advertise the Work.

I hereby release and hold harmless the Member, the U.S. House of Representatives, their employees and agents, and the United States from any and all liability for any and all claims arising out of or relating to use of my child’s Image in relation to the Work.

I have read and understand the terms listed above.

By:
______
Signature of Parent/Legal Guardian
______
Printed Name
______
Date / By:
______
Signature of Parent/Legal Guardian
______
Printed Name
______
Date

Authorization and Release

I, ______, hereby authorize U.S. Representative Larry Bucshon (the “Member”), to use my voice, portrait, picture, color or black and white photograph, audiovisual or other reproduction of me (collectively my “Image”) for any purpose relating to the official duties of the Member (“the Work”). I understand that the Member may use the Work in other media, or other technologies for worldwide distribution, and I grant my authorization for such use. Finally, I authorize the Member to use my Image to advertise the Work.

I have read and understand the terms listed above.

By:

______

Signature

______

Printed Name

______

Date