North Street Christian Reformed Church
Photo Release Consent Form
I hereby consent to be interviewed, photographed, filmed, videotaped, have my voice recorded, and/or
have my personal likeness recorded through other visual means (collectively, referred to as “Personal
Images”), and authorize the North Street Christian Reformed Church to use, release, publish, exhibit, post
on the Internet, in CD-ROMs or any other medium any of my Personal Images.
By signing this form, I hereby give permission to North Street Christian Reformed Church to use my
Personal Images in whatever medium deemed appropriate by North Street Christian Reformed Church for
any of the following purposes: (i) public relations; (ii) training and education; (iii) advertising; (iv) research;
and/or (v) online, in-store, internal, external sales and marketing activities.
I understand that information about myself/my child may be included in the advertising and publicity
material created by North Street Christian Reformed Church, and I agree that this authorization includes
I hereby waive all my rights to inspect and approve the finished product, its use or such written or spoken
copy as may be used in connection therewith.
I also waive all rights and release North Street Christian Reformed Church, its officers, agents and
employees, and each and all persons involved in creating my personal Images from any liability connected
with the taking, recording, filming or publication of said interviews, photographs, slides, computer images,
videotapes or voice recordings.
I declare that I am eighteen (18) years old or older and am legally competent to execute this Consent and
Release Form or that I have acquired the written consent of my parent or legal guardian. I understand that
the terms herein are contractual and not a mere recital, and that this Consent and Release Form is legally
binding on me.
Individual’s Name: _________________________________________________________________
Individual’s Signature: ______________________________________________________________
Phone Number: ___________________________________________