Form Center

2. Photo/Video Consent Release

   By typing my name in the box below I hereby provide consent and authorize City of Urbandale to reproduce, publish, circulate or otherwise use for promotional purposes any of the following of mine or of the minor for which I am the parent or guardian: name, portrait, photography/video, and/or voice in publications, billboards, radio and television commercials, advertisements, websites and all other forms of marketing and/or communications and I hereby release the City of Urbandale of and from any and all rights, claims, demands, actions or suits which I may or can have against it or its employees or agents on account of the use, publication and/or broadcast of said materials.

4. Where were you photographed?*

   Please type the name of the location or the event where your image was captured.

6. Date*
   Date

   Please type the date your image was captured.

8. Type your name here:*
   First and last name
Leave This Blank:


9. Submit

* indicates a required field