Media Release (Adult)
I consent to and authorize Good Counsel Learning Center and/or any of its related entities,
employees or agents to:

1. photograph, film, video, audio or otherwise electronically record me in such manner as the
Good Counsel Learning Center may choose;

2. use said photographs, film, video, audio or other electronic recordings (“the photographs or
other recordings"), and my name in connection with such photographs or other recordings,
for promotional and publicity purposes in its publications and otherwise to promote the
Good Counsel Learning Center and its mission, purposes, programs, and activities or for any
other use for its benefit;

3. transfer said photographs or other recordings to newspapers, television stations and
companies, radio stations and companies, Internet service providers, and any other mass
media, organization or person that customarily presents or provides information and news to
the general public (the “media”).

I further consent and authorize the media, in its discretion, to present to the general public all or
part of the information, photographs or other recordings and all information that the media may
gather or receive and expressly waive the right that I might have to request or demand that the
Good Counsel Learning Center or representatives of the media contact me prior to releasing any of
the said information, photographs, or other recordings to the general public.

I release the Good Counsel Learning Center from any and all claims, demands, causes of action or
damages that I may have by reason of the use of said photographs or other recordings or

I consent to and understand that the photographs or other recordings or information will become
the property of the Good Counsel Learning Center. This Consent and Release is given freely and
without the promise of compensation.
Name: *
Date: *
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