Story and photo release form

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Date conversion01.12.2016
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I understand that my story and photograph are being included in the Kate B. Reynolds Charitable Trust collection of stories and may be used in Trust publications and news releases, and on its website. I waive any right, title, and interest I may have in the photograph and story and agree to their use by the Kate B. Reynolds Charitable Trust for any purposes it would deem necessary and appropriate.
You may either fill out this form with your word processor, or by printing and filling out manually. In either case the subject of the story must sign this release form. Present the completed form to our staff, or fax/mail it to our offices, along with the story and photos.






City, State, Zip Code:


Signature of individual (or parent/guardian for minor child):

Date (mm/dd/yyyy):


Submitting Organization:





City, State, Zip Code:






Please present to a KBR staff member, FAX to the Kate B. Reynolds Charitable Trust at 336-723-7765, or mail to our offices at the address below.

Thank you for sharing this story.

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