Withdrawal of Media Consent

Per the IVA Liability Waiver, a User or Parent/Guardian may withdraw consent for the capture and use of media (photos, video, audio). By completing this form, you are requesting that IVA cease capturing new media of the individual(s) listed below and refrain from using their likeness in future marketing materials.

Participant Information

First Name (Participant)

Last Name (participant)

Is the Participant a Minor?

If Minor, Parent/Guardian Name

Relationship to Participant

Contact Information

Phone Number

Scope of Withdrawal

I hereby withdraw my consent for IVA to:

Capture new photography or video footageUse my/the minor's likeness in future social media posts (Instagram, Facebook, etc.Use my/the minor's likeness in future print or digital advertisements.

Acknowlegement of Limitations

Please initial each point below

I understand that this withdrawal applies only to media captured after the date this form is processed

I acknowledge that media already published (e.g., printed brochures, historical social media posts, or videos already in distribution) cannot be reasonably recalled or removed.

I understand it is my responsibility (or the minor's) to notify photographers/videographers on-site during special events that I have a withdrawal on file.

Thank you! Your submission has been received!

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