"By clicking "Submit" on this web form you are granting to the American Community Survey Office of the U.S. Census Bureau permission to reproduce, display, perform, disseminate, create derivative works from, and otherwise use for Governmental purposes any submitted image, photograph, attachment, or text, with the exception of email address and phone number (the "Submission Materials") in all media now existing or to be created in the future, including use of the Submission Materials (or portions thereof) in connection with the Census Bureau's programs.

I hereby represent and warrant that I am qualified to grant this permission, being the owner of the image, photograph, attachment, or text, or the owner's authorized employee or agent. I further warrant that I have obtained releases to use one's likeness from any individuals who might appear within the image, photograph, or attachment, or from their legal guardians or authorized representatives. I hereby indemnify and hold harmless the Census Bureau, its employees, agents, and contractors against any and all claims, actions, or damages (including attorney's reasonable fees) asserted by or paid to any party on account of a breach or alleged breach of the above warranties. I understand that the Census Bureau will not compensate me in any way or pay me for using the image, photograph, attachment, or text."