Name Please Print The undersigned authorizes the Division for the Visually Impaired to permit the use and display of said photographs images or interviews in publications multimedia productions ID: 204115
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Delaware Health and Social Services Division for the Visually Impaired 1901 N. Dupont Highway Biggs Building New Castle, DE 19720Media Consent FormSUBJECT COPY assistants, subcontractors and media representatives to Name (Please Print) The undersigned authorizes the Division for the Visually Impaired to permit the use and display of said photographs, images or interviews in publications, multimedia productions, displays, news releases, of both the individual and the sion may use name or likeness supplied by the undersigned. , or interviews, including but not limited to, any claims for invasion of privacy or defamation. form and/or have it read to me and explained to me in Signature of Subject Date ver (if applicable) Date Delaware Health and Social Services Division for the Visually Impaired 1901 N. Dupont Highway Biggs Building New Castle, DE 19720Media Consent Formassistants, subcontractors and media representatives to Name (Please Print) The undersigned authorizes the Division for the Visually Impaired to permit the use and display of said photographs, images or interviews in publications, multimedia productions, displays, news releases, of both the individual and the sion may use name or likeness supplied by the undersigned. , or interviews, including but not limited to, any claims for invasion of privacy or defamation. form and/or have it read to me and explained to me in Signature of Subject Date ver (if applicable) Date