THE ALS SOCIETY OF CANADA
MARCH OF FACES BANNER
Name (person in portrait): ________________________________________
Address (person in portrait): _______________________________________
City: ______________________________________
Province: __________________________________
Postal Code: _______________________________
E-Mail: ____________________________________
Contact Name: _______________________________
Year of Birth or Lifespan (eg. 1940 – 2004): _____________________________
Date of Diagnosis: _____________________________
PERMISSION WAIVER REQUIRED
By my own personal authority or by Power Of Attorney, I give permission to use the photograph of
______________________________ submitted to THE ALS SOCIETY OF CANADA to be printed on the ALS MARCH OF FACES Banner and THE ALS SOCIETY OF CANADA MARCH OF FACES Community Banner for the purpose of Awareness, advocacy and fundraising issues and events that concern and benefit People with ALS (PALS).
Signature: ________________________
Date: ____________________________
Completed form to be returned with a picture of the person named to:
George Goodwin
20 Congress Crescent, Apt. 401
Hamilton, On. L8K 5H7
Only pictures with a stamped self addressed envelope will be returned, pictures and permissions may also be sent by e mail to george.goodwin@sympatico.ca. For further information please contact George Goodwin at the above address or e mail address or call 905-578-3247. Thank you.
© ALS Independence 2003-08