Hooves to Heal, NFP
20604 Collins Rd., Marengo, Illinois, 60152
Patty Mozal ~
Consent for use of Image, Name and Information
The undersigned hereby consents to and authorizes the use and reproduction by Hooves to Heal, NFP and its media forums of any and all images of me (via photographic, computerized, and/or videotaped reproduction) use of my name, and use of my volunteering information for educational, promotional, marketing, exhibition, or other purposes for the benefit of Hooves to Heal, NFP or the program. I understand that Hooves to Heal, NFP may use my image, name, and information for the benefit of the Hooves to Heal, NFP program. I consent to Hooves to Heal, NFP use of my image, name and information at any time, and for an unlimited amount of time in duration.
I acknowledge that when using an image which discloses only a portion of my face or body, Hooves to Heal, NFP makes no representations, promises or warranties that I will not be recognized by anyone who views the material merely because the image reveals my likeness only in part.
I acknowledge that, even though I have consented to the use of my image, name, and information, Hooves to Heal may choose not to use these for educational, promotional, marketing, exhibition, or any other purposes. Hooves to Heal, NFP is not obligated to use my image, name, or information simply because I have signed this consent.
I acknowledge that, even though I have consented to the use of my image, name and information, I will not receive any financial or other form of remuneration, including, but not limited to, therapeutic services, for use of these images, name, and information.
I acknowledge I have read, understand, and voluntarily agree to comply with this consent.
Signature:_____________________________________________________________________________
Name:___________________________________________________________Date:________________
Address: ______________________________________________________________________________
Phone Number: ________________________________________________________________________
I DO NOT consent the use and reproduction by Hooves to Heal, NFP of any and all photographs, videotaped, or computerized materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the center.
Signature:_____________________________________________________________________________
Name:___________________________________________________________Date:________________
Address: ______________________________________________________________________________
Phone Number: ________________________________________________________________________
Parent or Guardian, if individual is under 18 years of age.
Signature:_____________________________________________________________________________
Name:___________________________________________________________Date:________________
Address: ______________________________________________________________________________
Phone Number: ________________________________________________________________________
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