Student Media Release Consent Form

I, _____________________________________________, hereby agree and give my permission for the Pilgrim Lutheran School/Church and/or partners to record, film, photograph, audiotape or videotape my/my child’s name, image, student work, and performance. I also give Pilgrim Lutheran permission to display, publish or distribute these Works for the purpose of publishing, posting on the PLS website, posting in schools, posting on social media sites and/or for broadcasting on television or radio as determined by the PLS.

I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or unknown, and I waive any right to any royalties related to the use of these Works.

I understand that my child or anything in regards to my child may appear in electronic form on the internet or in other publications outside of the Pilgrim Lutheran control.  I agree that I will not hold the Pilgrim Lutheran responsible for any harm that may arise from such unauthorized reproduction.      

I also understand that external media organizations may attend school events.  I give permission for my/my child’s name, image, student work, and performance to be photographed, filmed, audio-taped or videotaped for the purpose of being published and/or broadcast on-line, on television or radio.

Student’s Name: ____________________________________________________________       Grade: ___


Parent’s/Guardian’s Name: _____________________________________                                                                        

Parent’s/Guardian’s Signature (If student is a minor – under the age of 18):                                 

Date: _________