Delaware Health and Social Services
Division for the Visually Impaired
1901 N. Dupont Highway
Biggs Building
New Castle, DE  19720


MEDIA CONSENT FORM


The undersigned does hereby authorize:

The Division for the Visually Impaired (DVI) and/or its associates, 
assistants, subcontractors and media representatives to 
photograph/film/interview:

Name (Please Print):  __________________________________________


Purpose:  _____________________________________________________


______________________________________________________________

The undersigned authorizes the Division for the Visually Impaired to 
permit the use and display of said photographs, images or interviews 
in publications, multimedia productions, displays, news releases, 
advertisements, or website to raise public awareness, generate 
support and promote positive images of both the individual and the 
Division.

The undersigned agrees the Division may use name or likeness 
supplied by the undersigned.

The undersigned releases and forever discharges the Division from 
any and all claims and demands arising out of or in connection with 
the use of said photographs, images, or interviews, including but not 
limited to, any claims for invasion of privacy or defamation.

My signature indicates that I have read this form and/or have it read 
to me and explained to me in a language that I can understand.

Accepted and Agreed:


__________________________  __________
Signature of Subject	Date

_____________________________________________________  __________
Signature of Legal Parent/Care Giver (if applicable)	Date


SUBJECT COPY

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Division for the Visually Impaired
1901 N. Dupont Highway
Biggs Building
New Castle, DE  19720


MEDIA CONSENT FORM


The undersigned does hereby authorize:

The Division for the Visually Impaired (DVI) and/or its associates, 
assistants, subcontractors and media representatives to 
photograph/film/interview:

Name (Please Print):  __________________________________________


Purpose:  _____________________________________________________


______________________________________________________________

The undersigned authorizes the Division for the Visually Impaired to 
permit the use and display of said photographs, images or interviews 
in publications, multimedia productions, displays, news releases, 
advertisements, or website to raise public awareness, generate 
support and promote positive images of both the individual and the 
Division.

The undersigned agrees the Division may use name or likeness 
supplied by the undersigned.

The undersigned releases and forever discharges the Division from 
any and all claims and demands arising out of or in connection with 
the use of said photographs, images, or interviews, including but not 
limited to, any claims for invasion of privacy or defamation.

My signature indicates that I have read this form and/or have it read 
to me and explained to me in a language that I can understand.

Accepted and Agreed:


__________________________  __________
Signature of Subject	Date

_____________________________________________________  __________
Signature of Legal Parent/Care Giver (if applicable)	Date


DIVISION COPY