Release and Permission for use of Name, Image or Private Information
I, _______________________________________________, (“the Participant”) hereby grant permission to:
_________________________________________________ (“the Contestant”) to use my name, image and/or private information as part or all of the contents of a submission to the College of Liberal Arts and Sciences of Iowa State University for its
“Impacting the Future” contest. If the submission is the winning entry, I also grant to
Iowa State University the right to use the contents of the submission, including my name, image or private information (as applicable), without compensation or further permission, for its own promotional purposes.
I hereby release Iowa State University from any claim of whatsoever nature based upon use of the submission in accordance with this release and the Official Contest
Rules.
This Release and Permission shall be effective unless revoked by me in writing by submission of the revocation to 202 Catt Hall, Iowa State University prior to 5:00 p.m.
November 2, 2009.
Name:
Signature:
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_______________________________________
Date: _______________________________________
If the Participant is below the age of 18 years old, a parent or guardian must sign:
Parent or Guardian: _______________________________________
Signature:
Date:
_______________________________________
_______________________________________

Additional Group members
Name: _______________________________________
Signature: _______________________________________
Date: _______________________________________
Name:
Signature:
Date:
Name:
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Signature:
Date:
Name:
Signature:
Date:
Name:
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Signature:
Date:
Name:
Signature:
Date:
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