Media Release Form

Please fill out the following form.

I hereby give Todd Mission Food Pantry permission to use my story, which include quotes and identifying details, and any photos/videos/audio recordings of me without limitation or reservation. I agree to the use of my story and likeness in all of Todd Mission Food Pantry's communications and materials, which includes, but is not limited to, print publications, social media, the internet, and Todd Mission Food Pantry's website. I grant Todd Mission Food Pantry permission to share this information with media sources such as print or on-line publications. I waive any right to compensation for the use of my story or my likeness.

First name

Last name

Phone

I certify that I am 18 or older.

I certify that I am the parent or guardian of the individual above, a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this General Media Release.

Parent or Guardian's Name

Signature

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I declare that the info I’ve provided is accurate and complete.