Multimedia Release Consent Form

I hereby consent irrevocably and in perpetuity to the use and reproduction of any and all multimedia images taken of me at any time by The Ohio Masonic Home, its employees, agents, representatives, assigns, and licensees, in any form of media whatsoever, which said use may include, but not be limited to, advertising, promotional or trade purposes. This consent is also granted for the use of any printed matter used in conjunction with any multimedia. I hereby waive all rights to approval of the finished product and/or printed matter accompanying its use. I understand and acknowledge that the copyright for, and ownership of, all multimedia images relevant to this document shall be the sole property of The Ohio Masonic Home and/or its assigns.

I hereby warrant and represent that I am of legal age and of sound mind to execute this document. I further warrant that I have read this document and I understand its contents and implications. I understand that this authorization is voluntary and subject to written revocation at any time by notifying The Ohio Masonic Home of revocation, in writing, delivered to:

Ohio Masonic Home
Director of Marketing
2655 West National Road
Springfield, Ohio 45804-3695


By submitting this form, I am agreeing to the above statements and considering this to be my electronic signature.