Permission & Photo/Video Release Form

If you are older than 17 please put your name in the parent/guardian box as well and sign as parent guardian.

Name of Parent/Guardian :*

First NameLast Name

Name of Participant*

First NameLast Name

Additional Participants

IF there is more than one child please enter here.

Age (s)*

Please use commas between ages, and put them in order of participants.

I hereby consent to the visual/audio images of any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips, accompanying written descriptions, and/or any other type of media now or hereafter known, taken of my child and myself captured during programming and events, through video, photo, and digital camera, to be used solely by The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners, for podcast material as well as promotional material and publications. I hereby waive any rights of compensation or ownership thereto.*

Parent Initials

Do you give permission for your child to ride the RTS bus, for field trips with staff?*

YesNoType option 3

Do you give permission for your child to ride in an uber for field trips with staff?*

YesNoType option 3

Do you give permission for your child to ride in a vehicle for field trips with staff, that is owned by a licensed and insured staff member?*

YesNoType option 3

Do you give your child permission to participate in clean sweep?*

YesNo

Do you give your child permission to participate in community apprenticeship?*

YesNo

Do yo give your child permission to be on news media outlets?*

YesNo

Do you give your child permission to speak to local elected officials*

YesNo

Do you give your child permission to participate in extracurricular activities? (Swimming, Horseback Riding, Sports, Flipping, gardening, Walking etc).*

YesNo

Do you give your child permission to participate in group or therapy circles or individual social support meetings?*

YesNo

All statements and visual/audio images of any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips, accompanying written descriptions, and/or any other type of media now or hereafter known, being taken of my child(ren) or myself by The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners may be used and/or authorize the use of my child’s or my own video/audio images and/or my child’s pr my own name in any manner or media without notifying me -- such as but not limited to, websites, publications, presentations, exhibitions, broadcasts, podcasts advertisements and/or posters. as anywhere in the world in its sole discretion. determined by Neither Minor nor I shall have any right to control the use or publication of the statements, photographs, and/or audio or video recordings.*

Parents/Participants Initials

All statements, the visual/audio images of any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips, accompanying written descriptions, and/or any other type of media now or hereafter known, being taken of my child(ren) or I by The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners, shall be the sole property of The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners, Neither the Minor nor I shall receive any compensation in connection with use of these statements, photographs, and/or audio or video recordings for may use and/or authorize the use of my child’s video/audio images and/or my child’s name in any manner or media without notifying me -- such as but not limited to, websites, publications, presentations, exhibitions, broadcasts, advertisements and/or posters or other purposes.*

Parents/Participants Initials

This Release shall be binding upon my child(ren) and I, and our respective successors, heirs, assigns, executors, administrators, spouse and next of kin.

On behalf of my child (ren) and myself, I hereby release, waive and discharge any claims or right to inspect or approve the finished images, prints, or any electronic matter of any kind or nature arising out of, or relating to the use of the visual/audio images of any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips, accompanying written descriptions, and/or any other type of media now or hereafter known, recordings against by The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners, or any person or firm authorized by The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners, to publish said materials ("Publisher").*

Parents/Participants Initials

Such release, waiver, and discharge shall also extend to all affiliated companies, shareholders, directors, officers, trustees, employees, administrators, successors, agents and assigns by The B. E. R. R. Society LLC and Infinite Mindz Learning Pods Inc. or its partners, and any Publisher from any claims, damages, or liabilities which Imay ever have in connection with the taking of or use of my child’s or my own visual/audio images and/or my child’s or my own name.*

Parents/ Participants Initials

I HAVE READ THIS DOCUMENT AND I UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS ON BEHALF OF THE MINOR AND MYSELF (INCLUDING RIGHTS RELATING TO PUBLICITY AND PRIVACY WITH RESPECT TO THE COMMERCIAL USE OF ANY STATEMENTS, PHOTOGRAPHS, AND/OR AUDIO OR VIDEOAND RECORDINGS) I SIGN THIS RELEASE FREELY AND VOLUNTARILY*

Parents/ Participants Initials

Date*

Date

Name of Person Signing*

First NameLast Name

Signature of Parent/Guardian*