U.S. Department of Justice 

Office of Community Oriented Policing Services 

145 N Street NE 

Washington, DC 20530 

800-421-6770 

www.cops.usdoj.gov 

Community Policing In Action Photo Contest 

Instructions: Te law enforcement agency must ensure that a Privacy Consent, Waiver, and Release form is completed 

by each individual recognizable in the photograph(s) or, in the case of a minor, from each minor’s parent or legal 

guardian. Please reprint this form as necessary and include all signed originals with the law enforcement agency’s 

ofcial photo contest submission. 

PRIVACY CONSENT, WAIVER, AND RELEASE 

AUTHORIZING USE AND DISCLOSURE OF PHOTOGRAPHIC IMAGE 

Notice to Individuals 

The United States Department of Justice (DOJ), Office of Community Oriented Policing Services (COPS Office), 

is seeking photographs from law enforcement agencies for the Community Policing in Action Photo Contest. Tere 

is no cash award or other prize associated with the photo contest. Selected photographs may be featured in DOJ 

press releases, web content, e-newsletters, publications, presentations, documents, reports, and social media posts 

for ofcial business purposes. Selected photographs will be disseminated to the public via DOJ websites, or DOJ’s 

authorized accounts on third party websites (including, but not limited to, Facebook, YouTube and Twitter), or in any 

other media format. Te collection of photographs for the photo contest is authorized pursuant to 5 U.S.C. § 301, 

44 U.S.C. § 3101, and the Violent Crime Control and Law Enforcement Act of 1994, Pub. L. No. 103-322, 108 

Stat. 1796 (1994). Te photographs will be used and disseminated primarily to support DOJ’s missions, including 

enabling the COPS Ofce to advance the practice of community policing by the nation’s state, local, territorial, and 

tribal law enforcement agencies through information and grant resources. Providing permission to DOJ to use your 

photographic image is entirely voluntary. 

Consent, Waiver, and Release by Individuals 

By signing below, 

I Authorize DOJ to collect photograph(s) containing my photographic image from law enforcement agencies for the 

photo contest and use, disclose, and disseminate my photographic image to the public to support DOJ’s missions as 

stated above. 

I Understand that DOJ has no control over how third parties may use or disseminate my photographic image featured 

in any of the DOJ formats available to the public as described above. 

I Understand that my photographic image may, in some instances, be protected by the Privacy Act of 1974 (5 U.S.C. 

§ 552a) and if so, any DOJ use, disclosure, and dissemination of that information would be subject to the consent and 

other provisions of the Privacy Act. I also understand that my photographic image will be used, maintained, secured, 

and disseminated as provided in the relevant DOJ system of records notice, available at https://www.justice.gov/opcl/ 

doj-systems-records. 

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U.S. Department of Justice 

Office of Community Oriented Policing Services 

145 N Street NE 

Washington, DC 20530 

800-421-6770 

www.cops.usdoj.gov 

I Understand and Agree that under photo contest rules DOJ will retain a non-exclusive, irrevocable, and royalty-free 

license to use, or authorize others to use, my photographic image in any format for Federal Government purposes. I 

also understand and agree that I waive any right to royalties or other compensation or fees arising from or related to 

such uses of my photographic image. 

I Agree to waive, release, and hold harmless DOJ and its components, bureaus, divisions, ofces, employees, 

contractors, agents, and assignees, from any and all claims of action or damages of any kind arising from, or in any 

way connected to, the use or dissemination of my photographic image as stated in this Privacy Consent, Waiver, and 

Release Authorizing Use and Disclosure of Photographic Image form. 

I Certify that I am at least 18 years of age (or if under 18 years of age, that I am joined herein by my parent or 

legal guardian) and that this consent, waiver, release is signed voluntarily, under no duress, and without expectation 

of compensation in any form now or in the future. Tus, by signing below, I hereby consent to the release and 

disclosure to the public of my photographic image collected or captured about me on this day, the ____ of 

______________________, 20 __. 

To be completed by individual recognizable in photograph: (Please print legibly.) 

Print Full Name 

Signature Date 

To be completed by the parent or legal guardian if individual recognizable in photograph is under 18 years of age: 

Print Parent/Legal Guardian Name 

Parent/Legal Guardian Signature Date 

To be completed by law enforcement agency representative: (Please print legibly.) 

Name of Law Enforcement Agency 

Brief (one-sentence) description of photo 

For any questions, please contact 800-421-6770 or e-mail tellcops@usdoj.gov. 

Community Policing In Action Photo Contest 

Privacy Consent, Waiver, and Release Authorizing Use And Disclosure of Photographic Image 

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