Christian Heritage : Family Outreach : Photo/Video Release Form

Photo/Video Release Form

Your Name (Required)

Parent/Guardian Name (Required)

Street or post office address (Required)

City, State, Zip Code (Required)

Phone number (including area code) (Required)

E-mail address

Please list the names and ages of each child attending the event individually in the spaces below.

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Name of child (Please list each child separately) (Required)

Age of child (Please list each age separately) (Required)

Name of child #2

Age of child #2

Name of child #3

Age of child #3

Name of child #4

Age of child #4

Name of child #5

Age of child #5

CERTIFICATION AND RELEASE STATEMENT

Are you the legal guardian of child(ren)?

I certify that the information given herein is true and complete and that the submission of this form is the same as my signing this form.

I hereby give permission for images and/or recording of myself and my minor child(ren) listed below, obtained via audio, video, photo, and/or digital camera, to be used soley for the purpose of Christian Heritage's promotional material and publication. I wave any rights of compensation or ownership thereto.

Today's date (Required)

Family Outreach

Photo/Video Release Form

CERTIFICATION AND RELEASE STATEMENT

info@chne.org