Photo Release For Minors - Girl Scouts Central Maryland

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Girl Scouts Central Maryland
4806 Seton Drive
Baltimore, MD 21215-3247
T 410 358.9711, 800 492.2521
F 410 358.9918
PHOTO RELEASE FOR MINORS
SERVICE UNIT#____________ TROOP #_____________________
DATE(S): _________________________________________________________________________________________________________
PHOTOGRAPHER/PRODUCER: _____________________________________________________________________________________
ASSIGNMENT: ____________________________________________________________________________________________________
COUNCIL (IF APPROPRIATE): _______________________________________________________________________________________
LOCATION: _______________________________________________________________________________________________________
ACTIVITY: ________________________________________________________________________________________________________
For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I hereby consent and agree
to the following:
1. I hereby grant to Girl Scouts of Central Maryland (GSCM), and others working for GSCM 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 Girl Scouts of Central Maryland,
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.
2. 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 Girl Scouts of Central Maryland.
NAME OF MINOR (please print):______________________________________________________________________________________
ADDRESS:_________________________________________________________________________________________________________
CITY__________________________________________________STATE_________________________
ZIP___________________
DAYTIME PHONE NUMBER: (_____)____________________ ADDITIONAL PHONE (optional) (____)____________________________
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.
NAME OF PARENT/LEGAL GUARDIAN (please print):___________________________________________________________________
SIGNATURE OF PARENT/LEGAL GUARDIAN (REQUIRED):____________________________________________________________
DATE:_____________________________________________________________________________________________________________
PARENT/LEGAL GUARDIAN EMAIL ADDRESS*:____________________________________________@___________________________
(*will not be used for any other purposes or distributed to third parties)
Any revisions to the text of this Release must be approved in writing by Girl Scouts of Central Maryland
prior to the activity in order for the changes to be effective.
PLEASE RETURN COMPLETED AND SIGNED RELEASE TO THE TROOP LEADER
03-302
3/2014

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