YS4CPM Media Release Form

First, Last Name *

School *

County

Age

Grade

Phone Number

Area Code Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Talent

Photo submission of participant * Note: submit as many photos as you like

Browse Files

Media Release
I grant permission to Project G.A.I.N and Youth Services for Choctaw,Pushmataha and McCurtain Counties (YS4CPM), its agents and assigns, to use my photo or video, and likeness for the purpose of promotion by Project G.A.I.N and YS4CPM for all forms, media and manners, for the following, but not limited to, news releases, photographs, video, audio, website, marketing, advertising, trade, promotion, exhibition for an indefinite period of time. I give unrestricted permission for images, videos, and recordings of myself to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these images may be used without further notifying me. I further acknowledge that I will not be compensated for these uses and Project G.A.I.N and YS4CPM owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release Project G.A.I.N and YS4CPM and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright. This release expresses the complete understanding of the parties.

I agree *

Yes

Transportation Release

I, _____________________________, give Youth Services for Choctaw, Pushmataha and McCurtain Counties(YS4CPM) permission to transport my child/ren ___________________________________________________ in agency owned vehicles to and from all activities and field trips, between all Youth Services for Choctaw, Pushmataha and McCurtain Counties Services. This permission slip is valid from June 2021 - May 2022

Your signature on this blanket permission slip allows your child/ren to attend scheduled summer camps, field trips, events with Youth Services for Choctaw, Pushmataha and McCurtain Counties Services at various camp locations which the child/ren are registered.

In case of emergency such as a natural disaster or national emergency, your signature on this blanket permission slip allows your child/ren to be transported by agency owned vehicle, First Responders or Youth Services for Choctaw, Pushmataha and McCurtain Counties Services, Inc. staff owned vehicle to the nearest disaster relief shelter. Youth Services for Choctaw, Pushmataha and McCurtain Counties Services will notify parent(s)/guardian(s) of children’s emergency location via telephone call. The emergency telephone number(s) we use to contact parents/guardians are listed on the child’s emergency form.

I understand that all necessary precautions will be taken by Youth Services for Choctaw, Pushmataha and McCurtain Counties Services for the safety of my child/ren.

Media Release

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