Release Form For Children'S Programs


Release Form for
Children’s Programs
Photo / Interview Release for Children
I hereby grant permission to the Nature Discovery Center to photograph and/or interview my child,
________________________________. It is my understanding that any photographs or interviews
Child’s Name
taken, or portions thereof, will be used for public view.
I agree to participate in this project without financial remuneration, and I understand that this releases
the Nature Discovery Center, and the photographer and/or interviewer from any future claims as
well as from any liability arising from the use of said photograph/interview.
Child’s Name
Street Address
City, State, and Zip Code
Parent/Guardian’s Signature
Parent/Guardian’s Printed Name
Authorization for Medical Services
I, parent/guardian of _________________________________________________, hereby designate the
Child’s Name
program leader and his/her designee to act in my behalf to authorize such hospitalization, medical atten-
tion, and/or surgery as may be required in an emergency because of illness or injuries sustained by my
child/ward while participating in Nature Discovery Center activities. I hearby assume all financial responsi-
bility for hospitalization, medical attention, transportation, and surgery provided. I request that I be con-
tacted within a reasonable time in the event of illness or injury requiring medical services.
In case of emergency, contact me at:
Home Phone: ____________________
Cell Phone:
Work Phone: ____________________
Parent/Guardian’s Signature
Parent/Guardian’s Printed Name
BELLAIRE, TX 77401 713.667.6550


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