Media Release Form

Media Release Form

The Reagan High School Arts Partnership, Inc.
Student/Contributor Name (Please complete ONE form PER individual)

First NameLast Name
The student/Contributor is
Date of Birth
Parent/Guardian Name (if Applicable)

First NameLast Name
Please provide a contact phone number or email address in case we need more information or to verify submission.
I, undersigned, agree with the selected option and Release Statement below:
RELEASE STATEMENT
By signing this release, I give The Reagan Arts Partnership, Inc. permission to make or use pictures, slides, videos, or digital images of me, or my minor child if completing for minor, or of materials owned by me or my child. I also give The Reagan Arts Partnership, Inc. permission to use those pictures, slides, or images, without payment, in broadcast productions, publications, on the Web, or in other materials related to The Reagan Arts Partnership, Inc.
By signing this, I am releasing The Reagan Arts Partnership, Inc. and its directors, officers, and agents from any future claims. I am also releasing The Reagan Arts Partnership, Inc. and its representatives from any liability arising from the use of any photographs or images. I certify that the information above is accurate and complete. By initializing, signing or typing my full name I am legally signing this form.
This form shall be valid until revoked by me (or my minor child upon reaching the age of 18.) This form can be revoked at any time in writing to The Reagan Arts Partnership, Inc.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian Signature
Adult Student/Contributor Signature
Should be Empty: