Scadian Name (Please Print)

Modern Name (Please Print)

Modern Signature

Email Address

I authorize ________________________________________ to publish photographs, taken on _______________, of myself and/or my work, in print and electronic media including publication on any Society for Creative Anachronism, Inc. Recognized Internet web site, for any non-commercial purposes related to the SCA. This permission is given with no promise or expectation of anything of value in return.