Authorization for use of Photo and Name Please attach this form to your submission. Name: First _____________________________ Last _____________________________ Address: ________________________________________________________________ City: ______________ State: __________ Zip Code: _____________________ Phone Number: _______________________ Cell: ________________________ Email: ___________________________________________________________ Date of Birth: _______________________ Age: __________________________ Type of Submission: ___________________ (Photo, article, art or poetry) ____ I give the Cultura Latina Magazine permission (If over 18) to use my: Photo Article Art Poetry Other_________________________________________ Or my child’s (If younger than 18) to use his/her: Photo Article Art Poetry Other_________________________________________ In any Cultura Latina Magazine(CLM), newsletters, emails and/or any form of media or promotion produce by CLM. ____ I give my permission to use my name in the Cultura Latina Magazine permission to use my name (if over 18) or my child’s name(if younger than 18) in any other Cultura Latina Magazine, newsletters, emails and/or any form of media or promotions produce by CLM. ____ I do not give my permission to use my name in the Cultura Latina Magazine permission to use my name (if over 18) or my child’s name(if younger than 18) in any other Cultura Latina Magazine, newsletters, emails and/or any form of media or promotions produce by CLM. ________________________________________ Signature of parent or guardian, or teen if over 18.
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________________________________________ Cultura Latina Magazine Publisher/Agent
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