Authorization And Release Form

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AUTHORIZATION AND RELEASE FORM
1.
PARTIES:
“MUSIC INSTRUCTOR”:
(Name of Music Teacher or Music Instruction Business)
“PARENT”:
(Name of Parent or Legal Guardian)
“CHILD”:
(Name or Names of Child or Children Covered by Authorization)
2.
AUTHORIZATIONS: By placing his or her initials next to the corresponding activity
set forth below, the PARENT authorizes the MUSIC INSTRUCTOR to undertake that
activity on behalf of the CHILD:
Initials
Activity
_________:
Use of photographs and/or videotapes of the CHILD for promotional or
educational purposes by MUSIC INSTRUCTOR.
3.
RELEASE:
The PARENT agrees to indemnify, release and hold harmless MUSIC
INSTRUCTOR, his, her or its agents and representatives, from any claims or causes of
action arising or related in any respect to the activity or the CHILD’S participation in
such activity.
DATE:
SIGNATURE OF PARENT:
14416.1

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