HTML Preview Minor Media Release Form page number 1.
School Name: __________________________________________________________
Media Release Form for Minor Children
Please provide all the information asked for below.
Name: __________________________________________
Parent/Guardian’s Name: __________________________
Home address: ___________________________________
___________________________________
I, Parent/Legal Guardian of (child’s name) _________________________ hereby grants
permission to A Legacy of Giving, its agents and assigns, to use above named child’s photo or
video, and likeness for the purpose of promotion by A Legacy of Giving for all forms, media and
manners, for the following, but not limited to, news releases, photographs, video, audio,
website, marketing, advertising, trade, promotion, exhibition for an indefinite period of time.
I give unrestricted permission for images, videos, and recordings of the child to be used in print,
video, digital and internet media. I agree that these images and/or voice recordings may be used
for a variety of purposes and that these images may be used without further notifying me.
I further acknowledge that I will not be compensated for these uses and the A Legacy of Giving
owns all rights to the images, videos, and recordings, and to any derivative works created from
them.
I waive any right to inspect the uses of any printed or electronic copy. I hereby release A Legacy
of Giving and its agents and assigns from any claims that may arise from these uses, including
without limitation claims of defamation or invasion of privacy, or of infringement of moral rights
or rights of publicity or copyright.
This Release expresses the complete understanding of the parties.
Signed: _________________________________________________________________
Printed Name:_____________________________________________ __________
Date: ___________________________________________________________________
Relationship: _____________________________________________________________