Photo Release and
Publication Consent Form
Dental Hygiene Program
For good and valuable consideration, I hereby consent and authorize Indian Hills Community College to reproduce,
publish, circulate and otherwise use for advertising purposes, my name and/or signature and/or portrait and/or
photograph and/or name of employee and that attached voluntary statement or statements of any part thereof,
in black and white or in colors in magazines, newspapers, rotogravure sections of publications, booklets, circulars,
posters, billboards, radio and/or television scripts, radio broadcast transcriptions and/or telecasts and all of forms
of publication or circulation, or any of them in advertising or any other publicity; and I hereby release said Indian
Hills Community College of and from any and all rights, claims, demands, actions or suits which I may or can have
against it or them on account of the use or publication of said material.
Name:
Signature: Date:
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