MEDIA RELEASE FOR MINORS
PROGRAM
I. Personal Information
Child's Name
*
First Name
Last Name
Child's Full Name
Parent/Guardian's Name
*
First Name
Last Name
Parent's Full Name
Parent/Guardian's Email
*
example@example.com
II. Media Release
Please consider granting this release to us, if at all possible, as our ability to successfully share our programs with new participants depends on having representative media.
If you would like to offer any notes or restrictions (e.g. "I only consent to my child being featured in group photos", please do so here):
I hereby grant free permission, subject to the conditions noted above, for Weaving Earth to use images of myself and child participating in their programs or events for outreach purposes, including but not limited to photo, audio, and/or video media.
Yes
No
Signature of Parent/Guardian:
*
Today's Date:
*
-
Month
-
Day
Year
Date Picker Icon
SUBMIT
Should be Empty: