BROTHER TO BROTHER / LITTLE BROTHER TO BROTHER MENTORING APPLICATION FORM

I, (the undersigned)     {parent1}   , hereby grant and authorize Brother to Brother / Little Brother to Brother Mentoring Program the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video of (name of the student on this application)  {studentName}      to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submission to journalists, websites, social media, and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or hereafter devised. This authorization shall continue indefinitely unless I otherwise revoke said authorization in writing.

I understand and agree that these materials shall become the property of Brother to Brother / Little Brother to Brother Mentoring Program and will not be returned.

I hereby hold harmless and release Brother to Brother / Little Brother Mentoring Program from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf or on the behalf of my estate.

If the person signing is under the age of consent, then this release must be signed by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of the named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

PLEASE SELECT ONE OF THE STATEMENTS BELOW.

BY SIGNING THIS APPLICATION YOU EITHER AGREE OR DISAGREE WITH THIS RELEASE FORM.