Parent Release Form for Media Recording
I, the undersigned, do hereby grant or deny permission to Saint Joseph College’s Past the Playground Project to use the image/video of my child, _______________________________, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Past the Playground Web site. O Deny permission to use my child’s image at all. O Grant permission to use my child’s image in the following ways (mark all that apply): O Limited usage: I want my child’s image used on printed materials only (no digital or video use). O Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by Past the Playground for a variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images. Parent/guardian signature_________________________________ Date_________________ Please make a copy of this form for your own records and mail or fax the original to: Marialice Curran Past the Playground Saint Joseph College 1678 Asylum Avenue West Hartford, CT 06109 USA If you have questions, contact Lauren DeSantis at [email protected]. |
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Past The Playground