YS4CPM Media Release Form

First, Last Name*

School*

County

Age*

Grade

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Talent

Photo submission of participant * Note: submit as many photos as you like for future advertisement.

Browse Files

Media Release

I grant permission to Youth Services for Choctaw, Pushmataha, McCurtain Counties (YS4CPM) and 580 Rec Center, its agents and assigns, to use my photo or video, and likeness for the purpose of promotion by YS4CPM and 580 Rec Center 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 YS4CPM and 580 Rec Center 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 YS4CPM and 580 Rec Center 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 YS4CPM/580 Rec Center permission to transport my child/ren in agency owned vehicles to and from all activities and field trips, between all YS4CPM/580 Rec Center.

Your signature on this blanket permission slip allows your child/ren to attend scheduled summer camps, field trips, events with YS4CPM/580 Rec Center 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 YS4CPM/580 Rec Center staff owned vehicle to the nearest disaster relief shelter. YS4CPM/58 Rec Center will notify parent(s)/guardian(s) of children's emergency location via telephone call and/or email. The emergency telephone number(s) and/or email(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 YS4CPM/580 Rec Center for the safety of my child/ren.

Please be aware that YS4CPM/580 Rec Center staff alone determine if and when vehicle transportation will be provided for our programs. YS4CPM/580 Rec Center makes no guarantee or promise of vehicle transportation as part of its programs and such transportation may be unavailable on short notice due to vehicle shortage, mechanical failure, qualified driver shortage, insufficient staffing and volunteers, or otherwise. When YS4CPM/580 Rec Center voluntarily makes such transportation available our goal is to provide this in a professional and safe manner.

I agree*

Yes

Student's Signature

Signature (Parent/Legal Guardian )