Applicable for Non ICF functions only.

ICF -- Serving Indian community since 1968

 Specific Use:___________________________

  I, (print full name)_________________________________________________ ,
  being eighteen (18) years of age or over, hereby grant permission to
  ICF Louisville, KY and its affiliates to photograph, and/or videotape
  me; and/or to supervise any others who may do the interview, photography,
  and /or videotaping; and/or to use and/or permit others to use information
  from the aforementioned interview and/or the aforementioned images in educational
  and promotional activities for the following without compensation.

   Signature:________________________________Date:____________________________

   Name:___________________________________________________________________

   Address:_________________________________________________________________

   Email:____________________________________Phone:__________________________

 Minor Child:

 Specific Use:___________________________

  I, (print full name)_________________________________________________ ,
  hereby grant permission to ICF Louisville, KY and its affiliates to photograph,
  interview and/or videotape my minor child,________________________________________
  and/or to supervise any others who may do the interview, photography,
  and /or videotaping; and/or to use and/or permit others to use information
  from the aforementioned interview and/or the aforementioned images in educational
  and promotional activities for the following without compensation.

   Signature ofParent/Guardain:_____________________________Date:_________________

   Relatioship:________________________________________________________________

   Name:____________________________________________________________________

   Address:__________________________________________________________________

   Email:____________________________________Phone:___________________________