Registration & Social Media Photo Release Form
Student's Name
*
First Name
Last Name
Student's Phone (for program updates)
Please enter a valid phone number.
Format: (000) 000-0000.
Graduation Year
Specific Health Concerns
Parent Name
First Name
Last Name
Parent Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
example@example.com
Authorization and Release
What is your preference regarding the use of your name?
I consent to the use of my first name only.
I consent to the use of my photographs anonymously.
Please check the boxes regarding your preference.
I authorize Be Student Center, Inc. to take my photographs.
I authorize Be Student Center, Inc. to use my photos on Facebook, Twitter, Instagram, and other social media or marketing platforms.
I agree that I will not receive any monetary compensation for usage of my photographs in social media platforms.
Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: