CONSENT AND RELEASE-MINOR

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(Print Student’s Name)

I hereby grant consent, authority, and permission to 

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and to those acting with the authority of that organization, to use, reuse, publish, republish, the name, statements or comments, likeness, picture, photographic image, or videotape or electronic image, or videotape or electronic image of the minor (under the age of 19 years) below, in whole or in part, or composite or distorted, without restriction as to changes or alterations, without prior approval, in conjunction with original or reproductions in color or otherwise, in printed or electronic form, made though any medium or media, for illustration, promotion, advertising, trade, or any other purpose whatsoever.

I understand and agree that I will not receive any compensation for the use consented to herein.  I hereby release, and discharge all persons acting under the consent granted above from all liability, cause of action or claim civil or criminal, by virtue of any distorted or use, intentional or otherwise, that may occur or produced in the taking or subsequent processing or publication of my name, statements, comments, or the images covered herein.

I hereby warrant that I am of legal age and have the right to contract, consent, or grant release for the minor  in the above regard.  I also warrant that I have read the above consent and release, prior to it’s execution, and that I am fully familiar with the contents thereof. This consent and release shall be binding upon me, my heirs, legal representatives and assigns. 

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SIGNATURE OF WITNESS				PARENT/GUARDIAN/CUSTODIAN

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DATE							SIGNATURE

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							MINOR

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