WIU Media Release Form

WIU Media Release Form

This form is to be completed by parents of students under the age of 18 participating in a live-streamed, video or audio recorded, or photographed event from the WIU COFAC Recital Hall.
Student Name*

First NameLast Name
Student Email*
example@example.com
Student Phone Number*
Please enter a valid phone number.
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Instrument*
Student Graduation Year*
Student School*
WIU Event Attended*
Parent Name*

First NameLast Name
I hereby give Western Illinois University its assigns, licensees, and legal representatives the irrevocable right to use my or my participating child's picture, portrait, photograph, and/or video image in all forms and media (including the Internet) by Western Illinois University, and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith.

I have read this release and am fully familiar with its contents.
Parent Signature*

Clear
Should be Empty: