Name of Minor
*
First Name
Last Name
Name of Parent or Legal Guardian
*
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorization and Release
What is your preference regarding the use of your child's name?
I consent to the use of my child's complete name.
I consent to the use of my child's first name only.
I consent to the use of my child's nickname
I consent to the use of my child's photographs anonymously.
Please check the boxes regarding your preference.
I authorize Micah Heath Audio, Video, Photo to take my child's photographs.
I authorize Micah Heath Audio, Video, Photo to use my child's photos on Facebook, 500px, Instagram, and other social media platforms.
I authorize Micah Heath Audio, Video, Photo to edit, alter, copy, or distribute the photos for social media advertising and marketing.
I agree that the photos all intellectual property rights of the photos belong to Micah Heath Audio, Video, Photo.
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: