In consideration of the mutual desire to help educate the public about illegal drinking and the dangers of drinking and driving, I hereby authorize MADD (Mothers Against Drunk Driving) National Office, State Office, Local Chapter, and MADD Partnership agencies to use the photo of:

in a slideshow/ brochure/ publication/ photo board/ billboard/ media campaign, to educate the public about the dangers of drinking and driving.  I understand that the photo(s) will be used by MADD for an unspecified period of time.  MADD will not provide any monetary compensation for any materials used.  I represent that I have the legal authority to give this authorization.

Please provide the following information: