INDY
  • WARRIOR STORIES
    • CURRENT WARRIOR
    • CURRENT LITTLE WARRIOR
    • PAST WARRIORS >
      • 2022 >
        • KELSEY THOMPSON
        • DEBRA MARTINI
        • MARK SANSOM
        • JEN STICH
        • JESSIE QUIMBY
        • CATHY DENKER
        • RODNEY KARLS
      • 2021 >
        • DAVE FAUST
        • BARB JOHNSON
        • DREW SEVCIK
        • JILLEEN YOGERST
        • SAMI KNOTT
        • EMILY SPRINGER
        • JEREMY SCHNEIDER
        • SUE RAMLER
        • BRANDON KRUMWIEDE
        • TRISH & CALLIE HIRSCH
      • 2020 >
        • CHRISTMAS WARRIORS
        • JUSTIN FORT
        • HILLARY LEWANDOSKI
        • LAURA KUTZERA-GAARDER
        • TAMMY MORGAN
        • DENNY STUDENSKI
        • BOB HUSS
        • GORDIE ST. AUBIN
        • BRAD HARRISON
        • ANDREA HARBARTH
        • CHRIS FICENEC
      • 2019 >
        • CHRISTMAS WARRIORS
        • SALLIE BELLICOT
        • HEIDI QUINLAN
        • SARENA NOURSE
        • WANDA & LAURIE CHRISTEN
        • JADEN HANSON
        • MARIANNE STEICHEN
        • PAIGE REARDON
        • ERIN REMME
        • SARAH STELZNER
        • TYLON REETZ
      • 2018 >
        • CHRISTMAS WARRIORS
        • THE MONAHANS
        • ELLIE CZECK
        • PETE STACHOWICZ
        • CALEB STUDENSKI
        • CHERYL MILLER
        • NATALIE NEWMAN
        • AUDRA POPP
        • BETH REDDEN-HARRISON
        • KALY GROVER
        • MELISSA DEYAEGER
        • JOE SCHEFFLER
    • THE ORIGINAL
    • LITTLE WARRIOR >
      • PAST LITTLE WARRIORS >
        • 2022 >
          • JACE SCHAFER
          • ARRIS NELSON
          • RYA RUDOLPH
          • KENNEDI BORG
          • TEIAN HARTWIG
          • BRANTLEY LENT
        • 2021 >
          • BRAYDEN GILDEA
          • CHI'ANNE SMITH
          • EDEN FABER
        • 2020 >
          • CLOE CRAYFORD
          • KALEB KLIMEK
          • ISLA MARROCCO
          • BRICE MCARDLE
          • NATALIE HUSTON
          • MASON THOMES
          • OLIVIA BALDWIN
          • LIAM WESTROM
          • BODHI CROSBY
          • JORI MORRISON
        • 2019 >
          • CAMILLA KARSCHNIK
          • HENRY TEIGLAND
          • KIERAN KLOSS
          • JAKE RODRIGUEZ
          • OLIVER OLTHOFF
          • LAYLA MATHEWS
          • PAETTON CANFIELD
          • LUCY KOEHN
          • LILLIAN JOHANNES
          • ALIZABETH LUDWIG
          • CADE ANDERSON
        • 2018 >
          • BELLA RADERMACHER
          • GRACE HOHENSTEIN
          • JACKSON JOHNSON
          • DREW BAUERLY
  • PROGRAMS/NOMINATE
    • Nominate a Monthly Warrior >
      • WARRIOR IMAGE CONSENT FORM
    • EMERGENCY FUND
    • Backpack Program
    • GVL THRIVE(Closed for 22)
    • WORLD CANCER DAY/LOVE MONTH
  • DONATE
    • DONATE
    • CAMPAIGNS >
      • 100 Miles in September
      • 30 Days of Comfort and Joy
      • GIVE TO THE MAX
  • SHOP
    • SALE
    • NEW!
    • UNISEX
    • WOMEN'S
    • CURVY COLLECTION
    • MEN'S
    • LITTLE INDY (Kids)
    • HATS
    • ACCESSORIES
    • GREETING CARDS
    • GIFT CARDS
  • EVENTS
    • BOW TIES & ARROWS GALA >
      • 2022 GALA
      • 2021 GALA
      • 2019 GALA
    • INDY'S BIRTHDAY PAR-TEE >
      • 2022 INDY'S BIRTHDAY PAR-TEE
      • 2021 BIRTHDAY PAR-TEE
    • INDY WATER LANTERN RELEASE
    • LITTLE WARRIOR WONDERLAND
    • THE TIME IS NOW: INDY WALK
  • GET INVOLVED
    • WARRIORS AT WORK
    • BECOME A BOARD MEMBER
    • VOLUNTEER
  • BLOG
  • ABOUT
    • IN THE NEWS
  • CONTACT
    • MEET OUR TRIBE
    • CONFIDENTIALITY AGREEMENT

CONSENT TO USE OF IMAGE FOR NON-COMMERCIAL PURPOSES: ADULT

I give my permission to INDY Foundation to use my photograph and image publicly to promote INDY Foundation, its services, and its activities.

I understand the images may be used in print publications, online publication, social media, presentations, websites, and other communications by the INDY Foundation.

I understand that as part of its publications, social media, presentations, websites, and other communications by the INDY Foundation, the INDY Foundation may disclose certain health information about me. “Health Information” is defined as any information, whether oral or recorded in any form or medium, that: (A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to any individual.” I consent to the INDY Foundation using and sharing my Health Information. Any exceptions to my consent must be given in explicit and written format to INDY Foundation along with this signed Consent to Use of Image for Non-Commercial Purposes form. I understand INDY Foundation is not a covered entity under the Health Insurance Portability and Accountability Act (HIPAA) and therefore is not required to provide any HIPAA notice(s) or waivers to me prior to its use of my Health Information.

I also understand that I will not receive any royalty payment, fee, or other compensation payable to me by reason of INDY Foundation’s use of the photograph or image.

I understand INDY Foundation may use my photograph and image for non-commercial purposes. 
Please complete below and submit to accept these terms. 


    By typing your name below, you are stating that the information provided on this page is read, understood and agreed upon.
Submit

CONSENT TO USE OF IMAGE FOR NON-COMMERCIAL PURPOSES: MINOR

I give my permission to INDY Foundation to use my child’s photograph and image publicly to promote INDY Foundation, its services, and its activities.

I understand the images may be used in print publications, online publication, social media, presentations,
websites, and other communications by the INDY Foundation.
​
I understand that as part of its publications, social media, presentations, websites, and other communications
by the INDY Foundation, the INDY Foundation may disclose certain health information about my child. “Health
Information” is defined as any information, whether oral or recorded in any form or medium, that: (A) is
created or received by a health care provider, health plan, public health authority, employer, life insurer,
school or university, or health care clearinghouse; and (B) relates to the past, present, or future physical or
mental health or condition of an individual, the provision of health care to an individual, or the past, present,
or future payment for the provision of health care to any individual.” I consent to the INDY Foundation using
and sharing my Health Information. Any exceptions to my consent must be given in explicit and written format
to INDY Foundation along with this signed Consent to Use of Image for Non-Commercial Purposes form. I
understand INDY Foundation is not a covered entity under the Health Insurance Portability and Accountability
Act (HIPAA) and therefore is not required to provide any HIPAA notice(s) or waivers to me prior to its use of
my child’s Health Information.

I also understand that I will not receive any royalty payment, fee, or other compensation payable to me by
reason of INDY Foundation’s use of the photograph or image.

I understand INDY Foundation may use my child’s photograph and image for non-commercial purposes.
​
I confirm I have the legal authority to sign this Consent to Use of Image for Non-Commercial Purposes on my
child’s behalf.


I understand INDY Foundation may use my photograph and image for non-commercial purposes.
Please complete below and submit to accept these terms. (You may list more than one minor that you are consenting for in the box.)

    You may list more than one minor that you are consenting for in the box.
    By typing your name below, you are stating that the information provided on this page is read, understood and agreed upon.
Submit
Home   About   Shop   Nominate   Contact    Retailers    Blog
DONATE ONLINE
Picture
  • WARRIOR STORIES
    • CURRENT WARRIOR
    • CURRENT LITTLE WARRIOR
    • PAST WARRIORS >
      • 2022 >
        • KELSEY THOMPSON
        • DEBRA MARTINI
        • MARK SANSOM
        • JEN STICH
        • JESSIE QUIMBY
        • CATHY DENKER
        • RODNEY KARLS
      • 2021 >
        • DAVE FAUST
        • BARB JOHNSON
        • DREW SEVCIK
        • JILLEEN YOGERST
        • SAMI KNOTT
        • EMILY SPRINGER
        • JEREMY SCHNEIDER
        • SUE RAMLER
        • BRANDON KRUMWIEDE
        • TRISH & CALLIE HIRSCH
      • 2020 >
        • CHRISTMAS WARRIORS
        • JUSTIN FORT
        • HILLARY LEWANDOSKI
        • LAURA KUTZERA-GAARDER
        • TAMMY MORGAN
        • DENNY STUDENSKI
        • BOB HUSS
        • GORDIE ST. AUBIN
        • BRAD HARRISON
        • ANDREA HARBARTH
        • CHRIS FICENEC
      • 2019 >
        • CHRISTMAS WARRIORS
        • SALLIE BELLICOT
        • HEIDI QUINLAN
        • SARENA NOURSE
        • WANDA & LAURIE CHRISTEN
        • JADEN HANSON
        • MARIANNE STEICHEN
        • PAIGE REARDON
        • ERIN REMME
        • SARAH STELZNER
        • TYLON REETZ
      • 2018 >
        • CHRISTMAS WARRIORS
        • THE MONAHANS
        • ELLIE CZECK
        • PETE STACHOWICZ
        • CALEB STUDENSKI
        • CHERYL MILLER
        • NATALIE NEWMAN
        • AUDRA POPP
        • BETH REDDEN-HARRISON
        • KALY GROVER
        • MELISSA DEYAEGER
        • JOE SCHEFFLER
    • THE ORIGINAL
    • LITTLE WARRIOR >
      • PAST LITTLE WARRIORS >
        • 2022 >
          • JACE SCHAFER
          • ARRIS NELSON
          • RYA RUDOLPH
          • KENNEDI BORG
          • TEIAN HARTWIG
          • BRANTLEY LENT
        • 2021 >
          • BRAYDEN GILDEA
          • CHI'ANNE SMITH
          • EDEN FABER
        • 2020 >
          • CLOE CRAYFORD
          • KALEB KLIMEK
          • ISLA MARROCCO
          • BRICE MCARDLE
          • NATALIE HUSTON
          • MASON THOMES
          • OLIVIA BALDWIN
          • LIAM WESTROM
          • BODHI CROSBY
          • JORI MORRISON
        • 2019 >
          • CAMILLA KARSCHNIK
          • HENRY TEIGLAND
          • KIERAN KLOSS
          • JAKE RODRIGUEZ
          • OLIVER OLTHOFF
          • LAYLA MATHEWS
          • PAETTON CANFIELD
          • LUCY KOEHN
          • LILLIAN JOHANNES
          • ALIZABETH LUDWIG
          • CADE ANDERSON
        • 2018 >
          • BELLA RADERMACHER
          • GRACE HOHENSTEIN
          • JACKSON JOHNSON
          • DREW BAUERLY
  • PROGRAMS/NOMINATE
    • Nominate a Monthly Warrior >
      • WARRIOR IMAGE CONSENT FORM
    • EMERGENCY FUND
    • Backpack Program
    • GVL THRIVE(Closed for 22)
    • WORLD CANCER DAY/LOVE MONTH
  • DONATE
    • DONATE
    • CAMPAIGNS >
      • 100 Miles in September
      • 30 Days of Comfort and Joy
      • GIVE TO THE MAX
  • SHOP
    • SALE
    • NEW!
    • UNISEX
    • WOMEN'S
    • CURVY COLLECTION
    • MEN'S
    • LITTLE INDY (Kids)
    • HATS
    • ACCESSORIES
    • GREETING CARDS
    • GIFT CARDS
  • EVENTS
    • BOW TIES & ARROWS GALA >
      • 2022 GALA
      • 2021 GALA
      • 2019 GALA
    • INDY'S BIRTHDAY PAR-TEE >
      • 2022 INDY'S BIRTHDAY PAR-TEE
      • 2021 BIRTHDAY PAR-TEE
    • INDY WATER LANTERN RELEASE
    • LITTLE WARRIOR WONDERLAND
    • THE TIME IS NOW: INDY WALK
  • GET INVOLVED
    • WARRIORS AT WORK
    • BECOME A BOARD MEMBER
    • VOLUNTEER
  • BLOG
  • ABOUT
    • IN THE NEWS
  • CONTACT
    • MEET OUR TRIBE
    • CONFIDENTIALITY AGREEMENT