Driven Leadership, Inc. Media Release Form: Name & Image Permission

I grant permission to DRIVEN LEADERSHIP INC and its subordinates, to use my name and/or photographs for use in DRIVEN LEADERSHIP INC publications such as recruiting brochures, newsletters, and magazines, and to use my name/and or photographs on display boards, and to use my name and/or photographs in electronic versions of the same publications or on the DRIVEN LEADERSHIP INC web site or other electronic forms or media. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and waive any right to royalties or other compensation arising from or related to the use of the photograph. I hereby agree to release, defend, and hold harmless DRIVEN LEADERSHIP INC and subordinates, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution. Please check the paragraph below which is applicable to your present situation: