For My Family

Photo & Video Release Form Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to JumpStart3, its affiliates and agents, to use my image, video and likeness and/or any recordings I submit in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness. This consent is given in perpetuity and does not require prior approval by me. Parental Release The parent or legal guardian of any included minor child(ren) hereby consents to and gives permission to the above on behalf of such minor child.