Excellence in Literacy

AUTHORIZATION FORM
General Release: Photograph/Video/Voice

I _______________________________________________ (please print name) hereby authorize The

Learning Exchange to use my photograph, video or voice recording for purposes related to the mission
of The Learning Exchange, including publicity, marketing and promotion of TLE and its
programs/services.

I certify that I have read and understand the above statement and I consent to the use of my
photograph, video or voice recording for the purpose/s stated.

Darlene Brown
Name Executive Director’s name

Signature Executive Director’s signature

Date Date

2100 blvd. des Laurentides, Vimont, Laval, Quebec. H7M 2R5

w w w. TL E lit e r a cy. co m T: 450-688-2933 ext. 3126 F: 450-663-1290 E-mail: TLE_literacy@yahoo.ca Skype: TLETLE1

OUTREACH TRAINING TUTORING SUPPORT PREVENTION AWARENESS