Media Release Form

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(INSERT Organization NAME)
MEDIA RELEASE FORM
By signing below I, Mr./Mrs./Ms.
(client name)
authorize the organization identified above to photograph the interior and exterior of my
home, myself, my family, and any work performed by the Weatherization Assistance
Program.
I understand the photos will be used for informational and instructional purposes only
and will not be used to generate a profit or for any other commercial purposes. I
understand the photos may be used throughout the country by other local, state and
federal agencies for informational and instructional purposes. I have not been
compensated nor will I seek compensation for the photos. I release the organization from
responsibility should a third party violate the terms of this release.
Signature
Date
Witness
Date

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