Items denoted with a red asterisk * are required.
 
 
 
 
 
I, the undersigned, do hereby consent and agree that

its employees, or agents have the right to take photographs, videotape, or digital recordings of my child and to use these in any and all media, now or hereafter known, and exclusively for the purposes selected below.
 
 
 
 
 
 
Date
 
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 * Child's Name
 
First Name
M.
Last Name

First Name / Last Name
 
 
 
Address
 
Address 1
Address 2
City
State
Zip Code
 
 
 
Phone
 
 -  - 
(XXX)-XXX-XXXX
 
 
 
Email address
 
 
 
 
Permission
 
 
 
 
Limited Usage
 





Check all that apply
 
 
 
Parent/Guardian Signature
 



By submitting this form you are providing an electronic signature that is providing the same permissions as a signed original.
 
 
 
 
 
 
 
 
 
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