Image Usage Permission Slip

I hereby give permission for my image or the image of a minor under my guardianship to betaken at Hope Lutheran Church in De Pere (includes: photograph and video). I also givepermission for these images to be published in the "Anchor Line" newsletter or on the WorldWide Web at www.hopedepere.org (home page), www.facebook.com (Hope De Pere), andwww.twitter.com (HopeDePere), unless otherwise noted*.

By singing below I understand that the images will be located on the World Wide Web and canbe seen throughout the world by people with access through the Internet. For security reasons,only first names will be used, unless otherwise noted*.

Minor's name Relationship to minor

Signature Date

* Note

04 January 2010, last revised