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I certify that I am at least 21 years of age, and having the right to contract in my own name and to the extent herein set forth.
I hereby irrevocably grant to The Salvation Army, its successors and assigns, its agents and those by whom it is commissioned, the absolute, unrestricted and unlimited license, right, permission and consent to use and reuse, disseminate, copyright, print, reproduce, publish and republish, for any and all trade purposes or commercial or other advertising or public purposes, and in any and all advertising, publicity, display, publication or media, my name, signature and likeness, and any portraits, pictures, photographic prints or other representations of me, or in which I may appear, or any reproductions or sketches thereof or parts thereof, photographic or otherwise, with such additions, deletions, alterations or changes therein as you in your discretion may make, either separately or together with my name or a fictitious name, or the name of another person, with or without any statements or testimonials made by me, or authorized by me which you may, in your discretion, prepare for use in connection therewith. I warrant that I have not limited or restricted the use of my name or photograph to the use of any organization or person. I hereby grant unrestricted use of audio tracks or text by The Salvation Army for such purposes as The Salvation Army may deem appropriate.
I hereby release and discharge The Salvation Army, its successors, assigns and agents from any and all claims and demands arising out of or in connection with the use of any of the foregoing, including any claims for defamation, invasion of privacy or violation of any statutory right.

Witness by my hand as noted and sealed this day.

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