Lifeline of Ohio Photo/Media Authorization Form

I irrevocably authorize Lifeline of Ohio to use my name (and my family if applicable), written statements/quotes, photographs and videos to promote organ, eye and tissue donation via digital, television, radio, newspapers, magazines, social media, websites, educational materials/displays, community presentations, billboards or other means. I hereby release Lifeline of Ohio from claims or liabilities that may arise from these uses. I acknowledge that this authorization is voluntary and without obligation from Lifeline of Ohio.

Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Email address

example@example.com

Signature

Clear

Date

If the person who signed above is under the age of 18, a parent/guardian must also sign and state their relationship.

Parent/guardian signature (if applicable)

Clear

Relationship