Please provide the following information to enable our staff to plan for your participation.
In consideration of my acceptance for participation in the Glance Gwinnett program, I do for myself, my heirs and personal representatives hereby and forever release Glance Gwinnett, its officers, employees, affiliates, successors and agents from any and all manner of actions, causes of action, debts, claims, demands or liability for any harm or injury I may sustain arising out of or in any way connected with my participation in the Glance Gwinnett program.
I make this release freely, and I acknowledge and assume all risks which may arise out of or may be connected with my participation in the Glance Gwinnett program.
The Glance Gwinnett program respects individual privacy and, therefore, must obtain a signed release form from any participant visibly recognizable in a photograph. Crowd scenes where no single person is the dominant feature are exempt.
These rules govern photographs intended for use in any Glance Gwinnett publication of a marketing or a public relations nature, such as newsletters, brochures, promotional items or other materials. Releases also must be obtained for photographs used on our website. These rules are not in effect when photographs are taken of news events.
I hereby grant the Glance Gwinnett program permission to interview me and/or to use my likeness in photograph/s and/or video in any and all of its publications and in any or all other media, whether known now or hereafter existing, controlled by the Glance Gwinnett program, in perpetuity. I will make no monetary or other claim against the Glance Gwinnett program for the use of the interview and/or the photograph/s and/or video.
My (typed) signature below indicates my agreement to the general release and photo release.
The TYPED SIGNATURE below will serve as my electronic signature. (Please do not insert any other type of digital signature.)
Date Format: MM slash DD slash YYYY
Please submit a headshot photo suitable for print. The photo should be in a common file format (jpg, gif), a minimum of 125 pixels wide, and no more than 4 MB in size. (It does not need to be a professional portrait.) If you do not have a photo at this time, please email a photo to email@example.com as soon as possible. This photo will be used for a directory of participants in your Glance Gwinnett session.
Accepted file types: jpg, gif, png, pdf.
This field is for validation purposes and should be left unchanged.