Photo Release Consent Form

Date

YYYY

Name

First Name

Last Name

Address

Child/Children's Names

First Name

Last Name

Photo Release Consent Form

By typing my name here, I hereby consent to the following statement: Without expectation of compensation (payment or gift), now or in the future, I hereby give my consent to Iowa Breastfeeding Coalition (IBC), its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent is unlimited in duration and does not require prior approval by me. I may revoke consent at any time by written letter sent to the IBC at iowabreastfeeding@gmail.com

Consent for Minor(s)

By typing my name here as the parent or legal guardian of the named minor child(children) above, I hereby consent to and give the same permissions as above on behalf of such minor child.