Parental/Guardian Publicity Release Form

Parental/Guardian Publicity Release Form

County of Bergen. One Bergen County Plaza, Hackensack, NJ 07601
Name of Child*

First NameLast Name
Activity*
Name of Parent/Guardian*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
I, the undersigned, do hereby give permission to the County of Bergen to:
1. Use the above-named child's name in any and all media for publicity purposes.
2. Use the above-named child's photographs in any and all media/TV for publicity purposes.
3. Make an audio/visual tape including the above-named child for publicity purposes.
Parent/Guardian Signature*

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This release expires one (1) year from the date of the signature above.
Should be Empty: