Form ETA 9182A ETA 9182A Release and Authorization to Photograph

SENIOR COMMUNITY SERVICE OMB Control Number: 1205-0400

EMPLOYMENT PROGRAM Expiration Date: XX/XX/XXXX

RELEASE AND AUTHORIZATION TO PHOTOGRAPH

I, (name) grant to ___________________________ (name of photographer and company) ("Photographer"), consent to being the subject of Photographer's photographic likenesses or pictures.

I do not grant Photographer the right to use, reuse, publish, or republish the photographic likenesses or pictures of me, or those in which I may be included, in any printed, digital, Internet, or other media for exhibition, except that, Photographer may provide the photographic likenesses or pictures of me to the Senior Community Service Employment Program of [insert grantee name] and of the United States Department of Labor for the purpose of advertising in promotion of the Senior Community Service Employment Program.

I waive any right that I may have to inspect or approve the finished product or the advertising or other copy, or the use of the portraits or photographic likenesses of pictures of me.

I release the Senior Community Service Employment Program of [insert grantee name] and of the United States Department of Labor from any and all claims for damages or libel, slander, invasion of privacy, or any other claim arising out of the consent to take the photographic likenesses or pictures of me.

Dated: ____________________ _____________________________ Signature

Witness: _____________________________

Name Printed

Identifier (color of shirt, etc.):

_____________________________________________________________________________

_____________________________________________________________________________

ACKNOWLEDGMENT

I have read this Release and Authorization and it was fully explained to me by a Senior Community Service Employment Program representative. Also, I understand that I have consented to taking photographs only for Senior Community Service Employment Program's use as described above.

^{Witness: _________________ Signature: ____________________}

(Parent or guardian must sign for a minor)

ETA-9182A

(Rev. 7/3/18)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes/hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workforce Investment, Room C-4510, 200 Constitution Avenue, NW, Washington, DC 20210 and reference the OMB Control Number. Note: Please do not return the completed ETA 9182A to this address.