DIY Photo Petition Release Form and Email

  1. Print this Photo Petition form (Open PDF Format) - Please follow the instructions on the form to write in your name, city, zip code and date in large letters in the space provide. 
  2. Photograph yourself holding this poster in front of you so your face and information are clear. - Take the photo without flash in a well-lighted room
  3. Upload your photos in the form below (under 5 MB) - Your photo will be displayed on the website, hcao.org. Uploading in your photo gives us permission to use it in any format, forum or medium to further the cause of the Health Care Is A Human Right Campaign.
  4. Complete the Photo Petition Release Form below

Healthcare for all Oregon Coalition Image and Audio Release Form

I give my permission to Health Care for All Oregon and its member organizations** and Health Care for All Oregon Education Fund to use my contact information below, my likeness, in any form, whether photographic or graphics, and my voice as recorded via audio or video. It may be used for any purpose in furtherance of the campaign to protect health care as a human right and in any format, forum or medium.

Items below followed by an asterisk (*) are required

Name *
Name
Oregon Addresses Only *
Oregon Addresses Only
Phone *
Phone
Affiliation(s):
Volunteer Opportunities
Please Check any that Apply: