Media Release Form
Photography by Nicole Zeilinger and Chris Campos
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Impulse Drum and Bugle Corps, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for education and awareness.This consent is given in perpetuity, and does not require prior approval by me. *
Student Name *
Your answer
Address *
Your answer
Parent/Legal Guardian Name (if under student is under 18)
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Impulse Youth Arts Organization. Report Abuse