C.H.A.M.P. Inc. Consent for Picture
I, (parent/guardian) of (child - if applicable), give permission for C.H.A.M.P Inc. to use the following information:
Name (for children: first name only), Town of residence, Photograph of any activity or event under the auspices of the Community Hands in Action Mentoring Program in which I (or my child, if applicable) may participate.
That information shall be used by the organization identified above solely for the following purposes:
Publicizing the activities or events of the C.H.A.M.P Inc. in the print (newspapers, newsletters, magazines, etc.) and electronic media (TV, radio, website).
I understand that no personal history information regarding or identifying me (or my child) will be used by the agency indicated above. The permission granted by the consent form applies solely to the identifying information herein described and may not be used for any other purpose not provided for herein. In giving this consent, I release Community Hands in Action Mentoring Program, C.H.A.M.P, their nominees and designees from any obligation or liability otherwise owed to me in connection with any personal or proprietary right I may have as a result of the sale, reproduction, or use of the above-referenced identifying information. This consent may be terminated at any time by me, but in the event that I do not exercise my right to terminate this consent, it shall automatically expire upon termination of my participation with the Community Hands in Action Mentoring Program, C.H.A.M.P, or if I within a reasonable time after I submit a written request to this agency that such use cease.
I agree to the statements mentioned above
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