Hope Lutheran Pioneers Digital Images and/or Video Release Form

Student's Name*

First NameLast Name

Student's Name

First NameLast Name

Student's Name

First NameLast Name

Student's Name

First NameLast Name

Parent or Guardian's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

In accordance with the Freedom of Information and Protection of Privacy Act, Hope Lutheran Evangelical Church and the Lutheran Girl Pioneers / Lutheran Boy Pioneers require consent to use personal information for the purposes of promotion of Hope Lutheran Pioneers and the Lutheran Girl Pioneers / Lutheran Boy Pioneers programs on a Local, District, and National Level.

I, the undersigned, do hereby consent and agree that Hope Lutheran Evangelical Lutheran Church and Lutheran Girl Pioneers / Lutheran Boy Pioneers have the right to use photographs and/or videos of my child beginning September 1, 2021 and ending on August 31, 2022 and to use these photographs and videos in any and all media, now or hereafter known; exclusively for the purposes of Hope Lutheran Evangelical Church and the Lutheran Girl Pioneer Program / Lutheran Boy Pioneer Program.

I further consent that my child's name and identity may be revealed therein or by descriptive text or commentary.

Yes, I give permission to publish my child's first name.No, I do not give permission to publish my child's first name.

Yes, I give permission to publish my child's name in Hope Lutheran CLOSED groups on Facebook.No, I do not give permission to publish my child's name in Hope Lutheran CLOSED groups on Facebook.

I do hereby release to Hope Lutheran Evangelical Church and Lutheran Girl Pioneers / Lutheran Boy Pioneers all rights to exhibit this work in print for the express purpose of furthering Hope Lutheran Evangelical Church and Lutheran Girl Pioneers / Lutheran Boy Pioneers program in the church, district, or national organizations only. I understand that there will be no financial or other remuneration for recording my child, either for initial or subsequent transmission or playback.

I also understand that Hope Lutheran Evangelical Church and Lutheran Girl Pioneers / Lutheran Boy Pioneers are not responsible for any expense or liability incurred as a result of my child's participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

I represent that I am the legal parent or guardian of this child and have read and understand the foregoing statement and am compentent to excute this agreement.

Signature*