If you want your photo and story to appear in the Families of SMA Photo Album, print out this form and complete and sign it. For complete instructions, please see Instructions for Submitting Photos. This service (posting of photos) is available only to members of Families of SMA. 

Mail release to:
Families of SMA (Photo Release)
PO Box 196
Libertyville, IL 60048

[   ]   I am a member of Families of SMA
[   ]   I grant permission to Families of SMA to use the enclosed photograph.
[   ]   I grant permission to Families of SMA to use the story /photo sent via e-mail (to photos@fsma.org ) to accompany the enclosed photograph. 
[   ] Please also use this photo /story in FSMA Directions newsletter


Photo should appear in (check one) —

[   ] Family Album 

[   ] Memorial Album

Information to appear with photo —

Name: 

City: 

State/Province: 

Country: 

SMA type: 

 
Birthday:  

Date of death (if memorial):

Additional info:
 

Contact information for person submitting photo —

Name: 

E-mail address: 

Street Address: 

City: 

State/Province: 

Zip/Postal Code:


Country: 

Signature: 

Relationship: 

Date: