(NEW) Girl Scouts River Valleys Media Release Form

Media Release Form

Photos and video captured by Girl Scouts River Valleys are used to help us promote Girl Scouts. Girl Scouts River Valleys does not include full names when images are used without permission from the subject of the photos. Media Release Forms only apply to the event/s you list on the form.
What is the name of the event/camp/program you and/or the minor are attending?*
Are you completing this form for a minor (under eighteen years old)?*

YesNo
Are you completing this form for an adult?*

YesNo
This form grants permission to Girl Scouts River Valleys and its approved media partners to use the photograph and video assets gathered at the event selected above. If you are completing this form for a different individual or purpose, please contact us.
Only a minor's parent/guardian over the age of eighteen (18) may submit this form on their behalf.*

Yes, I acknowledge that I am eighteen (18) years of age or older, and I am the parent or legal guardian of the minor listed below.
For Minor (Under Eighteen Years Old)
I hereby grant permission to Girl Scouts River Valleys and its approved media partners to use the image (photographs, audio or video collectively referred to hereafter as “material”) of the minor listed below for any promotional materials and publications in perpetuity. I also hold Girl Scouts River Valleys free and harmless of all liability arising out of the subsequent publication and use of the material and I waive right to royalties or compensation arising from or related to the use of the image.*

Yes, I grant permission.No, I do not grant permission
Name of minor under eighteen years old*

First NameLast Name
For Adult / Parent / Guardian
I hereby grant permission to Girl Scouts River Valleys and its approved media partners to use the image (photographs, audio or video collectively referred to hereafter as “material”) of the person listed below for any promotional materials and publications in perpetuity. I also hold Girl Scouts River Valleys free and harmless of all liability arising out of the subsequent publication and use of the material and I waive right to royalties or compensation arising from or related to the use of the image.*

Yes, I grant permission.No, I do not grant permission
Adult / Parent / Guardian Name*

First NameLast Name
Electronic Signature

By providing your electronic signature below, you are agreeing to the statement(s) on this form.
Adult / Parent / Guardian Signature*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Media Release Form

For Minor (Under Eighteen Years Old)

For Adult / Parent / Guardian

Electronic Signature