Buckle Up Phone Down Media Consent
I am certifying that my likeness is represented in this image and grant permission to SD EMS for Children/Buckle Up Phone Down for the use of the photograph(s), video(s), or electronic media images in any presentation of any and all kind whatsoever. No liability is assumed by SD EMSC/BUPD. I understand that I may revoke this authorization at any time by notifying SD Emergency Medical Services in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images/email info will be stored in a secure location and only authorized staff will have access to them. They will be kept so long as they are relevant and after that time destroyed or archived. No compensation is being provided for the image(s).
I also give permission for my name to be displayed/presented as having pledged.