MAY 21st 2016
9:00 AM - 3:00 PM
TEMPLE UNIVERSITY HOWARD GITTIS STUDENT CENTER
1755 N. 13TH STREET PHILADELPHIA PA 19122
2016 Youth Service Inc. ysiphilly.org
MEDIA RELEASE PERMISSION
I grant permission for Youth Service, Inc. to use my photograph and/or likeness in printed and electronic form in the organization’s publications. Youth Service, Inc. assures that my photograph, stored on their electronic network, will be used solely by their organization and will be password protected with limited access.
I also grant permission for any television, radio, newspaper, or internet-based media outlets present at the conference to use my photograph, likeness and/or video and audio recordings of me in print, broadcasted, or televised form for the purposes of news distribution.
Should I decide to terminate this consent I will contact the Executive Assistant at 215-222-3262, x23 and withdraw such consent. I will receive written notice of the withdrawal of my consent. This release is valid for one year from the date of my authorization. A copy of this consent will remain on file at YSI.