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PHOTO RELEASE FORM
[ ] I am a
member of Families of SMA Canada
[ ] I grant permission to Families of SMA Canada to
use the enclosed photograph.
[ ] I grant permission to Families of SMA Canada to use the
story /photo sent via e-mail
[ ] Please also use this photo /story in FSMA Canada
newsletter
Information to appear with photo:
| Name |
_____________________________________ |
| SMA
Type |
_____________________________________ |
| City
and Province |
_____________________________________ |
| Date of Birth |
_____________________________________ |
| Date of
Death (if memorial) |
_____________________________________ |
| Biographical Details |
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________ |
Contact information for person submitting photo:
| Name |
_____________________________________ |
| Email |
_____________________________________ |
| Address |
_____________________________________ |
| |
_____________________________________ |
| |
_____________________________________ |
| Signature |
_____________________________________ |
|
Relationship |
_____________________________________ |
| Date |
_____________________________________ |
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Mailing Address:
FSMAC - Photo Album
P.O. Box 97
Rivers MB R0K 1X0
Alternatively, you can scan the completed form
and email it to
bettylou@curesma.ca,
along with your photos and a story.
Updated January 24, 2009
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