Date: ______________________________

I ________________________ hereby give Philadelphia Mental Retardation Services permission to use the photographs taken of me and/or my family member and to reproduce the story and interview.

I understand that these will be used for the purpose of promoting a
positive public image of people with disAbilities and of providing support for
people with disAbilities and their families. This may take the form of a book, article or newsletter or some other publication or a presentation.

____________________________ __________________________
Printed Name                         Signature

____________________________ __________________________
Witness Name                         Signature

Printed Name and Signature of parent, guardian or advocate
if necessary:

____________________________________

Relationship: ____________________________________

Address: ____________________________________

____________________________________

____________________________________

Telephone: ____________________________________

Person obtaining release: _____________________________