Consent For Use Of Picture And/or Voice Form - American Legion Auxiliary
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1American Legion Auxiliary
Department of California
CONSENT FOR USE OF PICTURE AND/OR VOICE
NOTE: The information requested on this form is solicited under the authority of title 38, United States Code.
The execution of this form does not authorize disclosure of the materials specified below except for the
purpose(s) stated. The specified material may be used within the American Legion Auxiliary for authorized
purposes, such as for education of or promotion of the American Legion Auxiliary.
Contact information for individual being photographed or recorded
Name: _______________________________________________________________________________
Title: ________________________________________________________________________________
Address: _____________________________________________________________________________
Phone #:______________________________________ Email: _________________________________
I hereby voluntarily and without compensation authorize pictures and/or voice recording(s) to be made of me (or of
the above-named individual if the individual is legally unable to give consent). (specify the name of the event,
newspaper, magazine, television station, website, etc.)
Name of Event: ________________________________________________________________________________
Name of Newspaper, Magazine, television station, website: _____________________________________________
I understand that the said picture, video and/or voice recording is intended for the following purpose(s):
Describe the activity, if any to be photographer or recorded:
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________________________
I authorize disclosure of the picture and/or voice recording to (specify name and address of the
organization, agency, or individual(s) to whom the release is to be made)
Signature of Individual or other Legally Authorized Person __________________________ Date: _______
I have read and understand the foregoing and I consent to the use of my picture and/or voice as specified for
the above-described purpose(s). I further understand that no royalty, fee or other compensation of any
character shall become payable to me by the American Legion Auxiliary for such use. I understand that
consent to use my picture, video and/or voice recording is voluntary and understand that I may at any time
exercise the right to cease being filmed, photographed or recorded, and may rescind my consent for up to a
reasonable time before the picture, video or voice recording is used.
Signature of Interviewer or Individual obtaining Consent:
Name: _______________________________________________________________________________
Title: ________________________________________________________________________________
Address: _____________________________________________________________________________
Phone #:____________________________________________
Email: ______________________________________________
IMPORTANT: This form must always be completed prior to the making or using pictures, video or voice
recordings for publication for American Legion Auxiliary Junior member/s
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