Authorization and Release Raising Phoenix Temple University Form

Name*

First NameLast Name
Birth Date

MonthDayYear
Gender
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization and Release
What is your preference regarding the use of your name?

I consent to the use of my complete name.I consent to the use of my first name only.I consent to the use of my nicknameI consent to the use of my photographs anonymously.I consent to my name and photo for completion of program recognitionIi consent to photo from any RPTU event
Please check the boxes regarding your preference.

I authorize RPTU Photo to take my photographs.I authorize RPTU Photo to use my photos on Facebook, Twitter, Instagram, and other social media platforms.I authorize RPTU Photo to edit, alter, copy, or distribute the photos for social media advertising and marketing.I agree that the photos all intellectual property rights of the photos belong to RPTU Photo.I agree that I will not receive any monetary compensation for usage of my photographs in social media platforms.
Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty: