I, a family member of the deceased named above or an authorized designee, authorize and release the likeness of this person to be rendered in portrait form by an artist from Any One of Us. I understand that this original portrait will be received in the mail for my personal use. I agree that Any One of Us may use a print or image of the original artwork for public display on the internet, to spread awareness to systematic police brutality or gun violence in America.

I understand that no commercial profit will be made from the portrait or its use. I understand that the victims full name, workplace, school, or other identifiable details will not be shared or displayed.