Media Release Form

West Central Arkansas Planning and Development District Inc.

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I ________ , grant permission to West Central Arkansas Planning and Development District, hereinafter known as the "Media" to use my image (photographs and/or videos) to use for Media publications including: *

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I hereby waive the right to inspect of approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. *

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I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

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WCAPDD does not discriminate on the basis of race, color, national origin, sex, age, or disability in its program and activities (specifically 40 C.F.R. 5.140 and 7.95)

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