Christian Heritage : Beyond Prison : 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.

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

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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)

Beyond Prison

Photo/Video Release Form

CERTIFICATION AND RELEASE STATEMENT

info@chne.org