Preserving our Heritage
	Farm and Ranch Museum Phone  308  436-1989  PO Box  398, Gering NE   69341-0398

Image & Videotape Release Form

Participant's name:		Phone:
	(P R I N T)

Address:

City:

State:

Zip:

Participated Activity:

Participated Dates:

I hereby expressly grant to Farm And Ranch Museum permission to take my picture, videotape or audiotape me, and to use my image, voice, or image and voice in connection with later uses of this activity in all forms of media application.

Participant’s Signature

Date

Witness's name (P R I N T)

Witness's Signature

Date

I decline / refuse permission to take my picture, videotape or audiotape me, and to use my image, voice, or image and voice in connection with later uses of this activity.

Participant’s Signature to DECLINE

Date