Photograph/Video Authorization and Release

I, ____________________________ do hereby authorize the Connecticut Department of Energy and (Please Print Name)

Environmental Protection (DEEP) to use any photograph, video or likeness of

my (self / child for whom I am the legal or natural guardian) _________________________, for

(Please circle one)	(Please Print Name)

promotion of the DEEP’s activities, properties, facilities or functions in any public format, including but not limited to publication in the DEEP Website, Facebook or other social media website utilized by DEEP, brochure or other publication and/or press release. I understand that such promotion will be disseminated to the public and may be copied or otherwise reproduced. I hereby release the DEEP from any liability that may arise from the photograph, video or likeness of myself/son/daughter in such promotion, and from any liability that may arise from the dissemination of such promotion to the public or the use of the promotion by the public.

___________________________________	__________________________ Signature	Date

Rev. 6/28/2018

Photograph Authorization and Release

Server

2020-10-05

Kristen Bellantuono

TPL New Haven