I, the undersigned, do hereby consent and agree that________________________ , its employees, or agents have the right to take photographs, videotape, or digital recordings of me beginning on and ending on and to use these in any and all media, now or hereafter known, and exclusively for the purpose of______________________________ . I further consent that my name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to___________________________________ , its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.
I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.
I also understand that is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.
I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.
Name: Date:
Address:
Phone:
Witness for the undersigned:
Signature:
I,______________________________________ the undersigned, do hereby grant or deny permission to to use the image of my child,_________________________________ , as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Web site.
____Deny permission to use my child’s image at all.
____Grant permission to use my child’s image in the following ways (mark all that apply):
- Limited usage: I want my child’s image used within the setting only (not in the larger community).
- Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within or in the larger community. One example of this could be videos in parent education classes.
- Limited usage: I want my child’s image used on printed materials only (no digital or video use).
- Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by for a variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images.
Parent/guardian signature___________________________________ Date_________________
Please make a copy of this form for your own records and mail or fax the original to:
If you have questions, contact at_____________________________________ . |
