Photography Release-The California State Pta Form
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12327 L Street, Sacramento, CA 95816-5014
916.440.1985 • FAX 916.440.1986 • •
PHOTOGRAPHY RELEASE
Permission to use child’s
Permission to use adult image, name,
image, name and/or school.
organization name, and/or title.
I, ___________________________________,
I, __________________________________,
(Print Parent/Guardian’s Full Name)
(Print Full Name)
am the parent or guardian of:
am an adult 18 years of age or older.
_____________________________________,
_____________________________________
(Print Name of Minor Child)
(Print Title)
_____________________________________.
_____________________________________
(Print Name of Child’s School)
(Print School or Organization Name)
I hereby grant and assign the California State PTA, its units, councils, districts and legal
representatives, the irrevocable and unrestricted right to use and publish for editorial, trade,
advertising or any other purpose and in any manner and medium, including website and
internet promotion, all photographic, video, and digital images as indicated below:
o
o
PHOTO / IMAGE ONLY of my child.
PHOTO / IMAGE ONLY of myself.
o
o
PHOTO / IMAGE ONLY of my child with
PHOTO / IMAGE ONLY of myself with
SCHOOL NAME.
SCHOOL NAME or ORGANIZATION.
o
o
PHOTO / IMAGE of my child
PHOTO / IMAGE of myself with my
with my CHILD’S NAME,
NAME, my ORGANIZATION, and/or my
and my child’s SCHOOL’S NAME.
TITLE.
By signing this, I hereby release the California State PTA, its units, councils, districts and its legal represen-
tatives from all claims and liability relating to said photographs, video and digital images.
Date: __________________________________________
Parent/Guardian/Adult Signature:
__________________________________________________________________________
Print Name as Signed: ____________________________________________________________________________________
Address, City, Zip: ______________________________________________________________________________________
Telephone:
____________________________________
Email: ______________________________________________
Please complete and return to:
______________________________________________________________________________________________________
338
California State PTA Toolkit – 2013
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