Authorization for use of Photo and Name

Please attach this form to your submission.

Name:

First _____________________________ Last _____________________________

Address:

________________________________________________________________

City: ______________ State: __________ Zip Code: _____________________

Phone Number: _______________________ Cell: ________________________

Email: ___________________________________________________________

Date of Birth: _______________________ Age: __________________________

Type of Submission: ___________________ (Photo, article, art or poetry)

____ I give the Cultura Latina Magazine permission (If over 18) to use my:

Photo

Article

Art

Poetry

Other_________________________________________

Or my child’s (If younger than 18) to use his/her:

Photo

Article

Art

Poetry

Other_________________________________________

In any Cultura Latina Magazine(CLM), newsletters, emails and/or any form of media or

promotion produce by CLM.

____ I give my permission to use my name in the Cultura Latina Magazine permission

to use my name (if over 18) or my child’s name(if younger than 18) in any other Cultura Latina

Magazine, newsletters, emails and/or any form of media or promotions produce by CLM.

____ I do not give my permission to use my name in the Cultura Latina Magazine permission

to use my name (if over 18) or my child’s name(if younger than 18) in any other Cultura Latina

Magazine, newsletters, emails and/or any form of media or promotions produce by CLM.

________________________________________ ___________________

Signature of parent or guardian, or teen if over 18. Date

________________________________________ ___________________

Cultura Latina Magazine Publisher/Agent Date