ETA 9182B Consent for Use and Publication of Information

SENIOR COMMUNITY SERVICE OMB Control Number: 1205-0040

EMPLOYMENT PROGRAM Expiration Date: XX/XX/XXXX

CONSENT FOR USE AND PUBLICATION OF INFORMATION

The Employment and Training Administration/ Division of National Programs, Tools, and Technical Assistance/ Older Workers Unit of the United States Department of Labor and [insert grantee name] are hereby given my consent to (CHECK PROPER BOX):

[ ] use and publish video/film footage, pictures or photographic likenesses, in whole or in part, of (PRINT NAME CLEARLY) , who is identified by (COLOR OF CLOTHING), for the purposes of promoting the SCSEP.

[ ] use his/her name for the purposes of promoting the SCSEP.

[ ] use his/her statement(s) for the purposes of promoting the SCSEP. The statement is:

For the items checked above, I understand that this information may be used or published through any medium, including the Internet.

Any right to inspect or approve the finished product or the advertising or other copy of the designated material is waived.

The Employment and Training Administration/ Division of National Programs, Tools, and Technical Assistance/ Older Workers Unit and the United States Department of Labor, and all persons acting under the direct permission or authority of the Employment and Training Administration/ Division of National Programs, Tools, and Technical Assistance/ Older Workers Unit are released from any liability that may arise out of the use of the portraits, photographic likenesses, name, and/or statements if used for the purposes of promoting the Senior Community Service Employment Program (SCSEP).

^DATE: SIGNATURE:

(Parent or Guardian must sign for a minor)

WITNESS:

Name (Printed)

ACKNOWLEDGEMENT:

I have read this document and it was fully explained to me by a SCSEP representative.

WITNESS:

SIGNATURE:

(Parent or guardian must sign for a minor)

ETA-9182B

(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 9182B to this address.