Excellence in Literacy

AUTHORIZATION FORM
Photograph/Video/Voice Release: Specific Event

Event/Location:

I _______________________________________________ (please print name) hereby authorize The

Learning Exchange to use my photograph, video or voice recording taken during the above listed event
for purposes related to the mission of The Learning Exchange, including publicity, marketing and
promotion of TLE and its programs/services.

I certify that I have read and understand the above statement and I consent to the use of my
photograph, video or voice recording for the purpose/s stated.

Darlene Brown
Name Executive Director’s name

Signature Executive Director’s signature

Date Date

2100 blvd. des Laurentides, Vimont, Laval, Quebec. H7M 2R5

w w w. TL E lit e r a cy. co m T: 450-688-2933 ext. 3126 F: 450-663-1290 E-mail: TLE_literacy@yahoo.ca Skype: TLETLE1

OUTREACH TRAINING TUTORING SUPPORT PREVENTION AWARENESS