Name, Photo, and/or Video Release Form (minor child) Summer Music Institute • Western Illinois University

I do hereby give Western Illinois University its assigns, licensees, and legal representatives the irrevocable right to use my child's name (or any fictional name), picture, portrait, photograph, and/or video image in all forms and media (including the Internet) by Western Illinois University, and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith. I have read this release and am fully familiar with its contents.

Western Illinois University hereby assures the above person that said images will only be used for the non-profit furtherance of its educational mission and promotion of that mission.
Email address *
Student Name *
Parent Name *
Address *
Date *
MM
/
DD
/
YYYY
Your Child's Camp Session and Dates *
Appearance Description *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Western Illinois University. Report Abuse