Media Consent 

As an employee or guest of George Junior Republic (“GJR”) and its affiliates (George Junior Republic in Pennsylvania (GJR in PA), George Junior Republic in Indiana (GJR in IN), and/or George Junior Republic Preventative Aftercare (GJR PAC)), you have the right to consent to use of your personal information (name, image, likeness, voice, achievements and/or activities).

If consent is granted, the personal information can be used in each organization’s press releases, newsletters, photography, videos (including voices), recordings, fundraising materials, “broadcasts,” or other information dissemination provided on television, radio, computers, phones, social media, blogs, podcasts, mobile devices or apps, the GJR website, other websites or online services, and other existing or future ways to release information.

The personal information may be used locally, nationally, or internationally and in all possible existing or future media (now known or unknown). Purposes: The above-referenced media and photography opportunities support each organization’s advertising, fundraising, education, mission, programs, persons served, community, activities, or outreach efforts. By checking “Yes” and providing my signature below:

• I acknowledge that I have all the necessary permissions and lawful authority to provide this consent so that it is legally binding;
• I give consent to GJR in PA, GJR in IN, and/or GJR PAC agents and service providers to publish and/or release the personal information about myself identified above, all without payment to me, my child, if applicable, or any other party;
• I understand that I may withdraw this consent by writing GJR in PA, GJR in IN, and/or GJR PAC at 233 George Junior Road, Grove City, PA 16127, and I agree, for myself, that any withdrawal of consent will not affect any item already published based on the initial consent.