Media & Testimony Release Form

Media & Testimony Release Form
Organization: Church of Scientology of the Valley
Purpose: Consent for Use of Photography, Video, and Personal Success Stories
I. Grant of Permission
I, the undersigned, hereby grant permission to the Church of Scientology of the Valley (the "Church") to use photographs, video recordings, and/or written success stories or testimonies of the individual(s) named below for promotional, educational, or informational purposes. I understand that these materials may be used in various formats, including but not limited to:
- Weekly Email Newsletters (Mailchimp)
- Church Website and Social Media platforms
- Printed Bulletins, Anniversary Booklets, and Annual Reports
- In-service presentations and slideshows
II. Specific Permissions (Please Initial)

II. Specific Permissions (Please Initial)

Rows	Initial to Consent
Visual Media: Use of photographs and video recordings.
Written Content: Use of written testimonies or success stories.
Privacy Preference: Use of the child's first name only (last names withheld).

III. Participant Information
Full Name of Child / Participant:
Parent or Legal Guardian Name (if under 18):
IV. Release of Liability
I release the Church, its staff, and volunteers from any liability connected with the taking, recording, or publication of these items. I understand that I will receive no financial compensation for the use of these materials. I also understand that I may revoke this consent at any time by providing written notice to the Church office, though this will not apply to materials already printed or distributed.
V. Acknowledgment and Signature
By signing below, I acknowledge that I have read and understood the terms of this release.
Signature:
Date:

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Date
Note: This information is for internal church use only and will not be shared with third-party marketing organizations.
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