----------CONSENT FORM FOR RELEASE OF MATERIALS ----------

In consideration of our mutual desire to help educate the public about underage drinking and the dangers of drinking and driving, I hereby authorize Mothers Against Drunk Driving (MADD) National Office, State Office, Local Chapter, and third parties associated with MADD to use my name, likeness, image, voice, or appearance as such may be embodied in any pictures, photos, video recordings, audio recordings, audiotapes, digital images, stories, and the like, taken or made by or on behalf of MADD, or submitted by me to MADD the enclosed story and/or photo submitted (collectively, the “Materials”) for both commercial and non-commercial uses, including, but not limited to public service announcements (PSAs), social media posts, blogs brochures, publications, photoboards, billboards, media campaigns, radio or television interviews or other promotions, marketing, or fundraising campaigns.

I understand that MADD will use the Materials for an unspecified period of time.

I release MADD, its officers, directors, employees and volunteers from all liability that may arise in connection with this release.

I understand that MADD will provide no monetary compensation for Materials used.

By typing your name below, you swear and affirm that you are the individual completing the questionnaire, that you have the authority to complete and submit this questionnaire and any attachments, and that the information you have provided is true and correct to the best of your knowledge.