Petition For Membership - Michigan Jobs Daughters Form Page 2
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2Job’s Daughters International
Media Release Form
I grant permission to Job’s Daughters International and its subordinates, to use my name and/or photographs for use in
Job’s Daughters International publications such as recruiting brochures, newsletters, and magazines, and to use my name/and
or photographs on display boards, and to use my name and/or photographs in electronic versions of the same publications or on
the Job’s Daughters International web site or other electronic forms or media.
I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be
used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to
royalties or other compensation arising from or related to the use of the photograph.
I hereby agree to release, defend, and hold harmless Jobs Daughters International and subordinates, including any firm
publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and
against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any
misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may
occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.
Please check the paragraph below which is applicable to your present situation:
_____I am 20 years of age or older and I am competent to contract in my own name. I have read this release before signing
below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any
specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to
do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
_____I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully
understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions
regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be
interpreted as a free and knowledgeable acceptance of the terms of this release.
_____ I am the parent or legal guardian of the below named child. I do not wish to have photos printed or displayed of my
daughter and respectfully request that she be kept out of all Job’s Daughters photos, group shots and photos taken at
community and fun activities whenever possible. Although attempts will be made to remove my daughter from photos taken at
Job’s Daughters’ activities, I fully understand that Job’s Daughters International and its subordinates are not responsible for
photos taken by individual adults and other members of the Order.
Date: _______________________
Bethel No._______ Location _______________________________________
(City/State/Province)
Name
____________________________________________________________________________________
(please print):
Address: ___________________________________________________________________________________________
(Street)
(City)
(State/Province)
(Zip/Postal Code)
Signature: ______________________________________________________________________________
Signature of parent or legal guardian_________________________________________________________
(if under 20 years of age)
A copy of the form should be kept in the permanent files of the Bethel and a copy sent to::
Job’s Daughters International
Phone: 402-592-7987
233 W. Sixth Street
Fax:
402-592-2177
Papillion, NE 68046-2210
Email:
Print
Form 130 (Revised September, 2015)
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