Enrollment Form 3-Media Release
Consent and Release for Students to be Filmed/ Photographed/ Interviewed and for Use of Image/Voice/School Work
Parent/Guardian First Name and Last Name *
Your answer
Student 1 First Name and Last Name *
Your answer
Student 2 First Name and Last Name
Your answer
Student 3 First Name and Last Name
Your answer
Student 4 First Name and Last Name
Your answer
Student 5 First Name and Last Name
Your answer
Student 6 First Name and Last Name
Your answer
The parent/guardian name above hereby grants to The Children's Guild DC, and its employees and agents, their successors, and their assignee the right to record the image and/or voice, and use the artwork and /or written work of my child on videotape, on film, in photographs, in digital media and in any other form of electronic or print medium and to edit such recording at their discretion. I understand that my child’s full name, address and biographical information will not be made public without my express written permission. I further grant The Children's Guild DC, and its employees and agents, their successors, and their assignee the right to use, and to allow others to use, my child’s image and/or voice on the internet, in brochures, and in any other medium and hereby consent to such use. I hereby release The Children's Guild DC, and its employees and agents, their successors, and their assignee and anyone using my child’s image and/or voice, artwork and/or written work pursuant to this release from any and all claims, damages, liabilities, costs and expenses which I or my child now have or may hereafter have by reason of any use thereof. This consent and release form is valid through the end of the summer school session following the school year during which it is signed. I understand that the provisions of this release are legally binding. (check one) *
Required
I completed this form and I certify that the information above is accurate. Typed name below acts as the signature of the Parent/Guardian with whom the student lives. *
Your answer
Date *
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Notice of Non-Discrimination
In accordance with state and federal laws, The Children's Guild DC does not discriminate on the basis of actual or perceived race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, gender identity or expression, family status, family responsibilities, matriculation, political affiliation, genetic information,
disability, source of income, status as a victim of an interfamily offense, or place of residence or business.
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