PHOTO RELEASE

I, the undersigned Visitor/Hiker to the Appalachian Trail Visitor Center ("Visitor Center"), authorize and give consent to the Appalachian Trail Conservancy ("ATC") to use my "hiker photo" taken at the Visitor Center along with all information associated with the photograph for inclusion in an on-line searchable database of past, present, and future hikers and visitors to the Visitor Center. I further authorize the modification, reproduction, sale, copyright, exhibit, broadcast, electronic storage and/or distribution of any such photograph, video or electronic image at the discretion of ATC without limitations or reservations.
Visitor / Hiker Name: ______________________________________________________
Visitor / Hiker Signature: ___________________________________________________
Today's Date: ______________________________________________________

The following must be completed in the event the Visitor/Hiker is under 18 years of age:
I, the undersigned parent or guardian of the above named Visitor/Hiker, do hereby join in the foregoing release and give permission as the undersigned parent or guardian for ATC to use photograph, video or electronic images of the Visitor/Hiker in the manner described above.
Parent/Guardian Name: __
Parent/Guardian Signature:
Today's Date: ______________________________________________________

Please tell us your Trail name and the approximate date(s) the Polaroid(s) was (were) taken. This will help us identify the correct photo(s).
Trail name: _____________________________________________________________
Date of Photo(s): _______________________________________________________

And we'd really appreciate any current contact information you'd be willing to share. We will be emailing advance notification of the website's launch to any hiker who provides us with an email address.
Address: ______________________________________________________________
______________________________________________________________
______________________________________________________________
Phone #: ______________________________________________________________
Email: ______________________________________________________________

Please send the completed form to:

Terry Harley-Wilson
Mathers Museum of World Cultures
601 East 8th Street
Bloomington, IN 47408

Questions (or to submit scanned documents): atmuseum@yahoo.com