Visual/audio Image Parent Consent And Release Form

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Susan E. Carlson
Director of Instructional Television
VISUAL/AUDIO IMAGE PARENT
CONSENT AND RELEASE FORM
I, _____________________________________, grant permission to the United
Independent School District (hereinafter “District”), its employees and agents, to take and use
video/audio images of my minor son(s)/daughters(s), _________________________.
Visual/audio images are any type of recording, including but not limited to photographs, digital
images, drawings, renderings, voices, sounds, or video recordings. I agree that the District owns
the video/audio images and all rights related to them. The audio/video images may be used in
any manner or media without notifying me, such as District Instructional Television Programs,
publications, promotions, broadcasts, advertisement, posters, and theater slides, as well as for
non District uses. I waive on behalf myself, my son(s)/daughter(s) to inspect the finished
audio/video images or any printed or electronic matter that may be used with them, or to be
compensated by them.
I release the United Independent School and its employees and agents, including any firm
authorized to publish and/or distribute a finished product containing the audio/video images,
from any claims, damages or liability which I may ever have in connection with the taking of use
or the images or printed material used with the images.
__________________________________________________________________________
Parent/guardian name
__________________________________________________________________________
Relationship to child
__________________________________________________________________________
Address
__________________________________________________________________________
Home/Cell telephone number
__________________________________________________________________________
Date
_______________________________________________________
Person receiving consent form
_______________________________________________________
Department/School
8800 McPherson Rd. - Laredo, Texas 78045 - (956) 473-6244 - Fax (956) 473-6282
I.T.V. Form 806-002 Revised 10/2012

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