Fillable Special Permission Form - Girl Scouts Of Central Indiana (Page 2 of 2) in pdf

RELEASE FOR MINORS

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby

consent and agree to the following:

I hereby grant to Girl Scouts of the USA (“GSUSA”), and others working for GSUSA or on its behalf, and each

of its respective licensees, successors and assigns (each a “Releasee”), the irrevocable, royalty-free, perpetual,

unlimited right and permission to use, distribute, publish, exhibit, digitize, broadcast, display, modify, create

derivative works of, reproduce or otherwise exploit my name, picture, likeness and voice (including any video

footage of the same) (collectively, “Media”), or to refrain from so doing, anywhere in the world, by any persons or

entities deemed appropriate by GSUSA, for any purpose (except defamatory) including, without limitation, any

use for educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever

(whether known or hereafter devised) including, without limitation, on the internet, in print campaigns, in-store and

via television. I agree that I have no interest or ownership in any of the Media.

I shall have no right of approval, no claim to compensation and no claim (including, without limitation,

claims based upon invasion of privacy, defamation or right of publicity) arising out of any use, alteration, blurring,

illusionary effect or use in any composite form of my name, picture, likeness and voice. I agree that nothing in this

Release will create any obligation on GSUSA to make any use of the Media or the rights granted in this Release. I

hereby release and hold harmless Releasees from any claim for injury, compensation or negligence resulting or

arising from any activities authorized by this Release and any use of the Media by GSUSA.

Release for Minors (those under the age of eighteen): I, the undersigned, being a parent or guardian of the minor,

hereby consent to the foregoing conditions and warrant that I have the authority to give such consent.

Please check the box and sign the line on the front side of the permission form if you consent to the above.

RELEASE FOR MINORS

For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree to the

following:

I hereby grant to Girl Scouts of the USA (“GSUSA”), and others working for GSUSA or on its behalf, and each of its respective

licensees, successors and assigns (each a “Releasee”), the irrevocable, royalty-free, perpetual, unlimited right and permission to use, dis-

tribute, publish, exhibit, digitize, broadcast, display, modify, create derivative works of, reproduce or otherwise exploit my name, picture,

likeness and voice (including any video footage of the same) (collectively, “Media”), or to refrain from so doing, anywhere in the world, by

any persons or entities deemed appropriate by GSUSA, for any purpose (except defamatory) including, without limitation, any use for

educational, advertising, non-commercial or commercial purposes in any manner or media whatsoever (whether known or hereafter de-

vised) including, without limitation, on the internet, in print campaigns, in-store and via television. I agree that I have no interest or owner-

ship in any of the Media.

I shall have no right of approval, no claim to compensation and no claim (including, without limitation, claims based upon invasion

of privacy, defamation or right of publicity) arising out of any use, alteration, blurring, illusionary effect or use in any composite form of my

name, picture, likeness and voice. I agree that nothing in this Release will create any obligation on GSUSA to make any use of the Media

or the rights granted in this Release. I hereby release and hold harmless Releasees from any claim for injury, compensation or negligence

resulting or arising from any activities authorized by this Release and any use of the Media by GSUSA.

Release for Minors (those under the age of eighteen): I, the undersigned, being a parent or guardian of the minor, hereby consent to the

foregoing conditions and warrant that I have the authority to give such consent.

Special Permission Form - Girl Scouts Of Central Indiana Page 2