Fillable CONSENT TO USE OF NAME AND PICTURE I (Pennsylvania)

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CONSENT TO USE OF NAME AND PICTURE I (Pennsylvania)

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CONSENT TO USE OF NAME AND PICTURE
Address _______________________________________________________________________
City_____________________________________ State____________ Zip__________________
Phone___________________________________ Email ________________________________
I give my consent to the Pennsylvania Department of State to use my name and image,
including the use of said images on the world wide web, television and in magazines and
newspapers. I understand that I will not receive any compensation for the use of my image.
Student Name (please print)_______________________________________________________
Student Signature _______________________________________________________________
Date _________________________________________________________________________
For persons under the age of 18, this form must also be signed below by a parent or guardian.
Parent/Guardian Name (please print) _______________________________________________
Parent/Guardian Signature _______________________________________________________
Relation to minor ______________________________________________________________
Date _________________________________________________________________________
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CONSENT TO USE OF NAME AND PICTURE I (Pennsylvania)

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Completed 18 January 2021

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