KIWANIS INTERNATIONAL
I give my permission to publish the following information on the Internet.
My Name:____________________________________________________________
My Phone Numbers:_____________________________________________________
My Address:__________________________________________________________
My E-Mail Address:____________________________________________________
My Office or Position in the Club/District/Division:__________________________________
CLUB NAME:__________________________________
YES NO
Please check YES or NO for permission to publish images of your likeness on the internet.
This permission will remain in effect unless cancelled by me in writing.
___________________________________________________________
Signature
Date:_________________________________________
Note: Only fill in the spaces with information which you give permission for the District/Division/Club to publish.
Mail or Hand Deliver the Completed Form to the any of the following:
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