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Last Updated: 02-16-2020

We take your privacy very serious. 

Please complete the following Media Release Form. We intend to protect ourselves and our cause and in doing so, we must ask that you complete this form. Underaged participants and Guardians must print and complete THIS FORM.

I, (Submission FORM Name), grant permission to Picking Up The Pieces, Inc. (Non-Profit & Michelle Pepin, Founder, hereinafter known as the “Media” to use my image (photographs and/or video) for use in Media publications including:

Chose all that apply...

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.


Agreed - I am 20 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

By clicking "I Agree to Terms" and the information you've submitted, we will do our very best to comply. Should you see an error, please contact us immediately, and we will respond with absolute compliance. Thank you so much. #PUTP 

Thank you for our submission. You may change your decision at any time by completing in a new request.

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