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  1. We want to recognize all our First Responders and Medical Professionals during these difficult times! Submit a photo and a name so that we can give the recognition that is deserved!
  2. First Name, Last initial
  3. First Name, Last initial
  4. Please enter a contact email in case there are issues with your submission
  5. (Optional)
  6. Photo Release Consent
    By checking this box I hereby authorize the City of Madison Heights (“City”), and those acting pursuant to its authority a nonexclusive grant to: 1. Use my name in connection with these recordings. 2. Use, reproduce, publish, republish, exhibit, edit, modify, or distribute, in whole or in part, these recordings in all media without compensation for any purpose that the City, and those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts. These recordings may appear in a variety of formats and media now available to the City and that may be available in the future (e.g. print publications, video tapes, CD-ROM, Internet, mobile, digital). I hereby release the City and those acting pursuant to its authority from liability, claims, and demands for any violation of any personal or proprietary right I may have in connection with such use, including any and all claims for libel, defamation, or invasion of privacy. I understand that all such recordings, in whatever medium, shall remain the property of the City. I have read and fully understand the terms of this release.
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  8. This field is not part of the form submission.