Media Release Form - National Farmworkers Jobs Program

This form is optional. Please complete this form, if NFJP South Dakota may have permission to use photos or videos of you for promotional and/or educational purposes.

Hidden
Date Submitted
Your Name*
First Last
Media Release Consent*
- Consenting for Yourself
- Parent/Guardian Consenting for Child (under 18) or Adult
- Both
- For Staff-Uploading Media Release Manually
Media Release Adult Consent*
I Consent & Agree to the Following
I hereby grant to BHSSC – Black Hills Special Services Cooperative (hereafter referred to as BHSSC) permission and consent to publish my name and photograph (and by video photography) my image for use in BHSSC’s videos, printed publications, websites, and social media, and to freely use such images in the exhibition, advertising, editorial use and publicizing thereof as BHSSC, its assigns, successors and licensees may elect. I acknowledge that since my participation in videos, print publications, websites, and social media produced by BHSSC is voluntary, I will receive no financial compensation. I further agree that my participation in any videos, print publications, websites, and social media produced by BHSSC confers upon me no rights of ownership whatsoever. I also release BHSSC, its contractors, and its employees from any and all liability for any claims by me or any third party in connection with my participation.
Media Release Parental/Guardian Consent*
I Consent & Agree to the Following
I hereby grant to BHSSC – Black Hills Special Services Cooperative (hereafter referred to as BHSSC) permission and consent to publish my child's/participant's name (listed in this agreement) and photograph (and by video photography) my child's/participant's image for use in BHSSC’s videos, printed publications, websites, and social media, and to freely use such images in the exhibition, advertising, editorial use and publicizing thereof as BHSSC, its assigns, successors and licensees may elect. I acknowledge that since my participation in videos, print publications, websites, and social media produced by BHSSC is voluntary, I or my child/participant will receive no financial compensation. I further agree that my child's/participant's participation in any videos, print publications, websites, and social media produced by BHSSC confers upon me or my child/participant no rights of ownership whatsoever. I also release BHSSC, its contractors, and its employees from any and all liability for any claims by me, my child/participant, or any third party in connection with my child's/participant's participation.
Child's/Ward's Name Consenting for*
Enter your child's name. Separate by commas if you are consenting for one or more. Required for children under 18.
Phone*
Email

a copy of your Media Release form will be sent to you.
Your Initials (e-signature)*
Signature (e-signature)*
Upload Media Release Forms*
Media release forms can be uploaded as images via your phone or mobile devices (take a photo) or as pdf's. Depending on file size and network speed files may take some time to upload. Appreciate your patience!