____________________________________________________________________

 

 

     I hereby authorize the Western Region Chapter of the American Music Therapy Association, Inc. ("WRAMTA") to use my (or my child's/ward's) photographic or video image(s) in its web site, newsletter, or any other publication. WRAMTA may also distribute the image to newspapers, televisions or other media for use in stories or news items pertaining to WRAMTA or music therapy.

     I acknowledge that only WRAMTA is authorized to use the image(s). I am not giving my authorization for use of any image by any other organization, any individual music therapist or any other person or company. WRAMTA may not sell the image.

     I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken.

     I hereby release WRAMTA and its officers from any legal responsibility or liability for disclosure of the images.

     If the person whose image is being used is under the age of 18, this authorization must be signed by a parent or guardian.

 

____________________________________    

Name of person whose image is being used    

 

 

____________________________________

Name of parent or guardian, if applicable

 

 

____________________________________     __________________

Signature                                                      Date

 

We are now a Non-Profit Organization, along with WRAMTA, our parent organization.