Impact America Media Release Form

Photo and Video Release Form
Release Form for Minors (under age 18)
Child's Full Name

First NameLast Name
Parent/Guardian's Full Name

First NameLast Name
Parent/Guardian Email
example@email.com
Parent/Guardian Phone Number
(123) 456-7890Format: (000) 000-0000.
Parent/Guardian and Child Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to reveal your child's identity?
Release Form for Adults (age 18+)
Full Name

First NameLast Name
Email
example@example.com
Phone Number
(123) 456-7890Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to reveal your identity?
Event Information
Event/Activity Date

MonthDayYear
Name of the Event/Activity
(i.e., FocusFirst Vision Screening, SaveFirst Tax Site, SpeakFirst Debate, etc.)
Name of Location
(i.e., Smithfield Library, Lucky Duck Daycare, etc.)

Authorization and Release Agreement
I hereby give permission for representatives of Impact America to capture photographs, video, and/or sound recordings of me (or my child, if signing a Minor Release), to be used by Impact America, media organizations, and others acting with the permission or authority of Impact America in materials available to students, community partners, funders, and other stakeholders, including, but not limited to, publicity or promotional materials for Impact America.

I hereby waive any right to inspect or approve (a) the finished Media, (b) any printed matter that may be used in conjunction with the Media, or (c) the eventual use to which the Media may be applied. I also understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.
Please review and accept the following terms:
Client Signature
Client Signature (Alternate Option)
If you are unable to use the signature widget above, please type your name here. By doing so, you acknowledge that your typed name acts as your signature within this form.
Date Signed

MonthDayYear
Should be Empty:

Photo and Video Release Form