I, the undersigned, hereby consent to the reproduction, use, and/or exhibition of my photograph(s), a photocopy or photocopies of which are attached hereto, by Holt International Children's Services, Inc. ("Holt"). I further release Holt from any and all claims for damages for libel, slander, invasion of privacy, or any other claim based on use of the above-described materials. The consideration for this release is other than money, the sufficiency and receipt of which is hereby acknowledged by the undersigned. Neither Holt nor anyone associated with Holt has made any promise of any other compensation in relation to this release. This release extends to the employees, agents, licensees, successors, and assignees of Holt.

Photo Submission Form Holt may use these materials in the following manners: Holt International Magazine Holt's Website (www.holtinternational.org) All manner of media, including unrestricted use for purposes of education, publicity, advertising, trade, display, editorial, exhibits, fund raising, and art. I do further consent to the use of my photograph(s) by any other organization designated by Holt International Children's Services, including any other publisher, periodical, agency or client, and such photograph(s) may be used for any of the following purposes without any limitations or reservations: advertising, trade, display, editorial, exhibits, fund raising, and art purposes. Photo Information * indicates a required field *Name(s) of person(s) in photo: *Age(s) of person(s) in photo: *Country(ies) of Birth: Birthdate(s): *File name of submitted photo: Guardian's Consent The undersigned represents that he/she is the parent and/or guardian of the minor named above and represents that he/she has the legal authority to execute the preceding consent and release and hereby approves the preceding and waives any rights in the premises. *Name: Spouse's Name: *Address: *City: *State: *Zip: *Phone: *Email Address: I declare that I am more than 18 years old.