Media Release Form
I, the undersigned, hereby grant Black Homeschoolers of Central Florida("Organization") permission to use, exploit,
adapt, modify, reproduce, distribute, publicly perform and display, in any form now known or later developed, my image
or visual likeness, my name and/or my voice ) as specified in this Release & License and indicated above, throughout
the world, by incorporating it or them into publications, catalogues, brochures, books, magazines, photo exhibits, motion
picture films, videotapes, and/or other media (the “Works”) or commercial, informational, educational, advertising, or
promotional materials relating thereto.
I release, and hereby agree to indemnify, defend, and save harmless Organization, its agents, employees, licensees
and assigns (collectively, “Released Entities”) from any and all claims I, or any third party, may have now or in the future
for invasion of privacy, right of publicity, copyright infringement, defamation or any other cause of action arising out of
the use, exploitation, reproduction, adaptation, distribution, broadcast, performance or display of the Personal
I waive any right to inspect or to approve any Works that may be created using the Personal Information and waive any
claim with respect to the eventual use to which the Personal Information may be applied. The Personal Information may
be used at the Organization’s sole discretion, with or without my name or with a fictitious name, and with fictitious or
accurate biographical material, alone or in conjunction with any other material of any kind or nature except that
Organization will not use the Personal Information for any criminal or illegal purposes or in a manner inconsistent with
community standards of decency.
I understand and agree that Organization is and shall be the exclusive owner of all right, title, and interest, including
copyright, in the Works, and any commercial, informational, educational, advertising, or promotional materials
containing the Materials.
I am of full legal age and have read this release and am fully familiar with its contents. By their signature below, a minor’s
parent(s) or legal guardian(s) indicate, on behalf of their minor child, their full and unqualified consent to the terms of this
Release & License.
Typing your full name indicates consent for Black Homeschoolers of Central Florida, Inc to use images of you or your child in news releases and other educational material. *
I grant permission for
I do not grant permission for any of the above.
Child's First Name *
Child's Last Name *
Child's Age *
Parent First Name *
Parent Last Name *
Email Address *
Phone Number *
Child's Birthday *
Send me a copy of my responses.
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