Recipient Info:


I hereby give consent to The Single Parent That Could, Inc. (the “Organization”), and its partners, agents representatives, assigns, successors in interest and licensees, to photograph, audio record, and/or video record me and my child(ren). I grant the organization and its partners the irrevocable right to use the photograph, audio recording(s), and/or video recording(s) or any reproduction/modification in any
manner or medium throughout the world an unlimited number of times in perpetuity in advertising, trade, promotion, exhibition, or any other lawful purpose.

I understand that I will not receive and monetary compensation for the permissions I am granting herein. I hereby waive any right of inspection of approval of the uses to which the organization may put
the photograph, audio recording(s), and/or video recording(s). I acknowledge the organization will rely on this permission and hereby release and discharge the organization from any and all claims and demands arising out of or in connection with the photograph, audio recording(s), and/or video recording(s) or the exercise of the permissions granted here, including any and all claims for libel,
invasion of privacy, or emotional distress.

I understand that I cannot withdraw my consent after I acknowledge this form and that this consent and release is binding on me and my heirs, legal representatives, and assigns.

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(All information must be included or the application will not be submitted)