Image Release Form for Pathfinders and Adventurers

Image Release Form

Seventh-Day Adventist Church

Kentucky-Tennessee Conference

I hereby consent and authorize the Kentucky-Tennessee Conference of the Seventh-Day Adventists, or its assigns, to photograph and publish pictures, audio, and video of me and/or my child(ren), and use my name and likeness and/or my child(ren)'s name(s) and likeness. I understand that photographs may be printed, placed on the organization's various websites, and/or incorporated into promotional material such as brochures and videos.

I hereby waive any claim against the Kentucky-Tennessee Conference of Seventh-Day Adventists for personal or emotional damage which may arise in connection with the use of these photographs, my name, or my likeness.

I understand the following:
- Illegal or explicit photographs are NOT authorized under this agreement. Should this situation arise, the violating individual or parties are solely liable and are subject to all local, state, and federal laws.
- I am releasing all recorded images, audio and video, for the express use of the Kentucky-Tennessee Conference of Seventh-Day Adventists.
- Neither my child nor I will receive any compensation if our names or likeness is used by the Kentucky-Tennessee Conference of Seventh-Day Adventists.
- The Kentucky-Tennessee Conference of Seventh-Day Adventists and its assigns will hold the copyright to all photographs, videos and promotional material.
- Should I desire copies of photographs, videos, or audio recordings, there may be a cost involved.
- This release remains valid until revoked in writing.
If I am signing this form on behalf of a child, I certify that I am the parent or guardian of the child and I am over 18 years of age. A copy of this form shall be considered valid and shall serve the same purpose as the original.
Club Name:*
Adult's Name*

First NameLast Name
Adult's Signature if CONSENTING to IMAGE RELEASE (if you are declining this release, please skip to bottom section)

Clear
Date if CONSENTING to IMAGE RELEASE

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please write the names of any children you are including under this photo release.
Minor's name (1):
Minor's Date of Birth (1):

MonthDayYear
Date
Minor's Name (2):
Minor's Date of Birth (2):

MonthDayYear
Date
Minor's Name (3):
Minor's Date of Birth (3):

MonthDayYear
Date
IF YOU ARE DECLINING TO SIGN THIS RELEASE PLEASE STATE YOUR REASON HERE:
Print Name if DECLINING this IMAGE RELEASE:
Signature if DECLINING this IMAGE RELEASE:

Clear
Date if DECLINING this IMAGE RELEASE:

MonthDayYear
Date
Rev. 10/2014 by Conference Attorneys
Should be Empty:

Please write the names of any children you are including under this photo release.