Consent Form

Use & Release:

  1. I grant Versatile Impact LLC, and parties designated by Darryl Lewis the irrevocable right to use the name, likeness, image, voice, appearance and/or performance as captured by photographic, audio and/or video means (the “Product”) for release and/or reproduction in any medium for any legal purpose, including but not limited to social media, promotion, editorial, advertising, education, training, illustration, art, and general trade. 


  1. I acknowledge that I have no interest or ownership in the Product or the copyright in the Product, and that any use of the Product may be made without compensation or notice. I waive any right to inspect, approve, and/or otherwise control the use of the Product. 

Acknowledgment and Authorization (by signing, you agree to the following):

  1. I hereby authorize Darryl Lewis to photograph my employees, participants, and grounds, take motion pictures, and take video footage, for all media purposes.  


  1. I authorize the use of any such photographic or electronic reproductions for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Darryl Lewis. 

Right to Privacy  

I acknowledge that names may be revealed in the product or by descriptive text or commentary. However, Darryl Lewis may not publish my address, telephone numbers, or email address with the product without my permission.

Leave this empty:

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Signed by Darryl Lewis
Signed On: March 1, 2021

Signature Certificate
Document name: Consent Form
lock iconUnique Document ID: e80c9760c42b9652b02d2bc0866a78b93623a04b
Timestamp Audit
March 1, 2021 11:21 am -05Consent Form Uploaded by Darryl Lewis - IP