North Street Christian Reformed Church Photo Release Consent Form Page 2

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North Street Christian Reformed Church
Photo Release Form for Individuals under 18 years’ old
By signing this Consent and Release Form, I consent to allow the below named minor to participate in the
activities described above and allow the information obtained from the below named minor to be used and
shared as described above. I represent and warrant that (i) I am eighteen (18) years of age or older and am
legally competent to execute this Consent and Release Form under the laws of my country, (ii) I have the
legal authority to represent the above named minor (iii) I have read and understand this Consent and
Release Form and (iv) I have had an opportunity to ask questions about the use of the above named
minor’s Personal Images, understand their purported use, knowingly consent to such use and voluntarily
sign this Consent and Release Form on behalf of the above named minor.
Child’s Name: ___________________________________________________________________
Parent/Guardian’s Name: ___________________________________________________________
Parent/Guardian’s Signature: _________________________________________________________
Phone Number: ___________________________________________
Date: ________________

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