Tel: / 908-689-1118
Fax: / 908-689-6363
Email: /
Website: /

Photo/ Video Consent form

This consent will remain in effect for a period of one year:

January31, 2018 through January31, 2019

This release is requested for:

Individual’s Name: / Date:
Address: / Program
ABILITIES OF NORTHWEST JERSEY, INC. occasionally has a need for photos / videos for our marketing and news involving individual program participants. Photos / videos may also be taken for use in press releases throughout the year, Abilities’ web site ( Agency newsletters, Abilities’ Facebook page, general display in the centers and marketing or promotional materials.
*~* Please note that individual’s names are NOT used in any marketing materials,unless specific permission has been given.
I agree to allow Abilities to use the following: / Individual’s Photo / Individual’s contributions to the consumer Newsletter, such as photos, artwork or writings. / Videos of individuals at Day Programs and/or worksites
In-house –
-posters & bulletin boards
-consumer newsletter / YES / NO / YES / NO / YES / NO
Social Media-
-Abilities Facebook page
-Abilities Twitter feed
-Abilities community
newsletter and website / YES / NO / YES / NO / YES / NO
Marketing materials-
-press releases
-promotional materials
-brochures, flyers, letters
-Abilities produced
promotional videos / YES / NO / YES / NO / YES / NO

Please contact me to request specific release for items not permitted above. Name/number______

~Asignature is REQUIRED on back page ~

264 Route 31 North · PO Box 251 · Washington, New Jersey 07882

For photographs, videotapes, digital or other images or other materials used for marketing purposes, the signature below gives Abilities and parties designated by Abilities the right and permission to copyright and /or use, re-use and/or publish and republish photographs or portraits made through any media.
I waive any right to inspect or approve the finished photograph or advertising copy or printed matter in conjunction with it. I understand that Abilities may modify these materials and may decide not to use them. I release and save harmless any party acting for Abilities from and against any liability as a result of any distortion, blurring, or alteration, optical illusion, or use in a composite from either intentionally or otherwise that may occur in the taking, processing or reproduction of the finished product, its publication, or distribution. I assign Abilities all of my rights to these materials.
I understand that if my image/consumer’s image appears on Abilities of Northwest Jersey, Inc.’s website, it may be viewed and downloaded by any computer. I waive any claims against Abilities of Northwest Jersey, Inc. and agree not to hold Abilities of Northwest Jersey, Inc. responsible for use of my image/consumer’s image by a third party.
I have the right to contract in my own name or I am the legal guardian/ Power of Attorney with the authority to sign this waiver on behalf of the consumer listed above.
I certify that I have read or had read to me the contents of this form. I have had the opportunity to ask questions and all of my questions have been answered.

Signature is required:

Consumer (if own Guardian) / DATE

Legal Guardianor

Power of Attorney

/

DATE

**This release will be reviewed /renewed annually or as needed. **

11/05ann 002 pg.1

rev: 12/15, 1/17, 12/17, 1/18