General Media Release Form


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2) I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by (I understand that I may be identifiable from such photographic or electronic reproduction) Agreed and accepted by: Print Name Title Address City, State, Zip Phone Signature Date I am signing this form as an individual Yes No I am signing this form as a representative of a group, and have full authority to grant release for this group Yes No Name of group PARENTAL CONSENT I certify that I am the parent or guardian of the individual above, , a minor under the age of eighteen years..


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