Photo Release Form

Name of Photo Subject

Please list the name(s) of the individual(s) in the picture

Photo Subject/Guardian (if under age of majority)

First Name

Last Name

Street Address

City

Postal Code

State/Province

Phone Number

Please upload your picture(s)

Maximum 3 files.
56 MB limit.
Allowed types: gif, jpg, jpeg, png.

I, on my own behalf and/or on behalf of my child, give exclusive permission to La Leche League Canada to use my submitted photograph and/or recording of me and/or my child’s(ren’s) image and voice on still photographs, motion picture film, audio tape, video tape, or digital media and to use this material, and/or similar material provided to La Leche League Canada by me or third parties involved in events, in whole, or in part, now and in the future, through the media of television, film, internet, multi-media presentation, radio, audiotape, videotape, in printed form and display form for the promotion of La Leche League Canada. I, on my own behalf and/or on behalf of my child(ren) assign and transfer to La Leche League Canada any and all proprietary rights, including copyright, and waive all personality rights, which I may have or my child(ren) may have in this material.

Signature of Photo Subject or Guardian

Sign above