I, ____________________________, grant Optimist International my permission to
use a
picture/videotape of my son/daughter, _________________________________________,
for their
public relations purposes. Optimist International may use the image in any
publication they see fit.
My child is a member of ____________________________Junior Optimist Club.
Name
_______________________________________________________________________________
Date
________________________________________________________________________________
Phone number
_________________________________________________________________________
E-mail:_______________________________________________________________________________
Address:______________________________________________________________________________