Massachusetts Commission for the Blind

What has been the impact of having a guide dog in your life?(Required)

Optional: Upload a photo of you with your guide dog.

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Max. file size: 50 MB.

Consent for Photographs and Audio Visual Materials

The Massachusetts Commission for the Blind (MCB) educates and provides information to the public on the abilities of people with vision loss in the Commonwealth. As part of this awareness campaign, MCB promotes persons who are positive, productive, and independent members of the blindness community. This information is often provided through written stories, photographs, and audio visual presentations.

By completing the information below, you can play a role in public education efforts at MCB as we attempt to break down the attitudinal barriers that limit opportunities for success among people with vision loss.

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Consent Options(Required)

I have read and understand the above consent for photographs and audio visual materials release. I affirm that I am at least 18 years of age and do not require the consent of a legal guardian.

I am 18 years of age or older and have a legal guardian or I am less than 18 years of age, and I have obtained the required consent of my parent/guardian(s) as evidenced by their assent in the checkbox below.

I am the parent/legal guardian of the person indicated on this form and in the checkbox above, and I have read and understand the above consent for photographs and audio visual materials release.

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

Parent/Guardian Phone(Required)