Media release form of a minor - International Association for Hospice & Palliative Care

First name

Last Name

Email address

Repeat email address

City and country where you live

Today's date

Photo/image

Format accepted: JPG and PNG. Maximum file size: 10MB

To submit other type of photo/image, please contact the IAHPC Team.

I, hereby grant and authorize the International Association for Hospice and Palliative Care, Inc. (“IAHPC”), a Texas nonprofit corporation the right to use any photo and/or image of the following minor:

Minor’s Name

Minor’s age

Minor’s Date of Birth

This photo is a submission for the IAHPC Photo Contest.

I warrant that I am of full age and have every right to represent the minor in this regard.

The IAHPC may use any photos or videos of me and/or the minors in any lawful organizational materials, including, but not limited to, newsletters, announcements, flyers, posters, brochures, fundraising letters, annual reports, press releases, websites, social networking sites and other print and digital communications, without payment or any other compensation. This authorization extends to all languages, media, formats and markets now known or later discovered.

Description of the photo/image

This authorization shall continue indefinitely, and I may revoke it at any time by submitting a notice in writing to the IAHPC.

I hereby hold harmless and release the IAHPC from all liability, petitions, and causes of action. This release shall be binding upon the minor and me, and our respective heirs, legal representatives, and assigns. representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

I confirm that I have read the above authorization, release, and agreement, prior to its execution, and confirm that I am fully familiar with its contents.
I confirm that I have received written consent from the minor's parent/legal guarding to have their picture taken. (Download consent form for minor, print it and once completed, keep it in your files)