Media Release (Youth)
I, the parent or legal guardian of [NAME OF STUDENT] 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 [NAME OF STUDENT] in such manner as Good Counsel Learning Center may choose;

2. use said photographs, film, video, audio or other electronic recordings (“the photographs or other recordings”), and his or her name and my name in connection with such photographs or other recordings, for promotional and publicity purposes in its publications and otherwise to promote 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 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 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 information.

I consent to and understand that the photographs or other recordings or information will become the property of Good Counsel Learning Center. This Consent and Release is given freely and without the promise of compensation.
Name of Student: *
Name of Parent/ Legal Guardian: *
Date: *
Never submit passwords through Google Forms.
This form was created inside of Good Counsel Learning Center. Report Abuse