SAMPLE PHOTO SUBMISSION/PERMISSION WAIVER



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INTERNATIONAL ALLIANCE OF ALS/MND ASSOCIATIONS

MARCH OF FACES

We invite you to help promote ALS/MND AWARENESS by participating in the International Alliance’s March of Faces Banner!

ABOUT THE BANNER

The ALS/MND March of Faces Banner is a pictorial display of the courageous women and men, both past and present stricken with the fatal neuromuscular disease, amyotrophic lateral sclerosis, also known as Lou Gehrig's disease or motor neuron disease. PALS (person with ALS/MND) Kyle Hahn conceived the Banner in July 1997, as an advocacy and awareness tool.

1. The Photograph

Email a .jpg or .png version of a photo and attach this form to your message. Send all March of Faces submissions to the General Manager at alliance@als-.

Photos are resized to fit a portrait for banner imprint; landscape orientation photos will incur cropping.

You are welcome to include family or caregivers in the picture if you wish.

Photos in memoriam are accepted.

• Please note that all submissions from member associations to be displayed at the Annual Alliance Meeting must be received by 1 November.

2. The Submission Form Please include the following information with your submission:

FOR THE BANNER Include contact’s information if applicable:

PALS Name Contact Name

PALS Date of Birth Contact Email Address

PALS Diagnosis Date Contact Telephone

FOR OFFICE USE

PALS City State/Province

PALS Country

PALS E-mail

PALS Telephone

PALS Date of Passing (ONLY if in memoriam)

3. The Permission Waiver

By my own personal authority or power of attorney, I give permission to use the photograph of submitted to the ALS/MND March of Faces to be printed on the ALS/MND March of Faces Banner for the International Alliance Meeting for the purpose of awareness and advocacy.

Signature Date

Someone else may sign for the person with ALS/MND

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