OHIO FARM BUREAU FEDERATION, INC.

WAIVER AND RELEASE OF NAME/IMAGE The participant agrees to be photographed and/or videotape recorded by representatives of the ________________________ County Farm Bureau, a member of the Ohio Farm Bureau Federation. The undersigned participant hereby acknowledges the possible use of the participants image, name and/or business name, and voice in future publications or broadcasts by or on behalf of _______________________ County Farm Bureau, Ohio Farm Bureau Federation, Inc., Our Ohio Communications, Inc., and/or their affiliates (collectively referred to herein as OFBF ), and agrees as follows: 1. OFBF has the right to publicly display, reproduce, publish, post, broadcast, distribute and copyright any media containing the participants image, name or business name, and voice whether photographs, audio or videotape recording, in OFBF publications and broadcasts or such done on behalf of OFBF, without limitation as to place or time. It is understood that OFBF is not obligated to make any use of such photographs or videotape recordings. 2. Any photographs, negatives, prints, or videotape recordings taken by OFBF or its representatives of the participant remain the property of OFBF for its use in perpetuity. 3. The use of the participants photograph or videotape recording by OFBF or its representatives will not violate any rights of any person or organization. 4. Participant forever waives the right of privacy, intellectual property rights, and any other legal or moral rights, including those rights granted under Ohio Revised Code Chapter 2741, that may preclude the use of participants image, name and/or business name, or voice, or require permission to use them, and participant agrees never to sue or assert any claim against OFBF or their affiliates, agents and assigns, in relation to their use of those materials; 5. There shall be no right of approval nor compensation or other consideration received for the use of participants image, name and/or business name, or voice by OFBF or their affiliates, agents or assigns; 6. This waiver and release shall not be verbally modified. The undersigned participant, or the parent/guardian of the minor participant, affirms they understand the terms of this waiver and release and voluntarily consents to the terms. _______________________________ Name of Participant ________________________________ Street Address ________________________________ City/State/Zip _______________________________ Signature of Participant or Parent/Guardian of Minor Participant Is the Participant under 18 years old? _____ Yes _____ No (If yes, a parent/guardian must sign form) ________________________________ Date