Parent Release Form For Children/youth Media Recording printable pdf download

Parent Release Form For Children/youth Media Recording

Parent Release Form for Children/Youth Media Recording

I,______________________________________ the undersigned, do hereby grant or deny permission to

use the image of my child, ________________________ , as marked by my selection(s) below. Such

use includes the display, distribution, publication, transmission, or otherwise use of photographs,

images, and/or video taken of my child for use in materials that include, but may not be limited to,

printed materials such as brochures and newsletters, videos, and digital images such as those on the

Web site.

____Deny permission to use my child’s image at all.

____Grant permission to use my child’s image in the following ways (mark all that apply):

____ 1. Limited usage: I want my child’s image used within the setting only (not in the larger

community).

____ 2. Limited usage: I want my child’s image used for educational materials only (not marketing).

This could be either within or in the larger community. One example of this could be videos in parent

education classes.

____ 3. Limited usage: I want my child’s image used on printed materials only (no digital or video

use).

____ 4. Unrestricted usage: I give unrestricted permission for my child’s image to be used in print,

video, and digital media. I agree that these images may be used by for a variety of purposes and that

these images may be used without further notifying me. I do understand that the child’s last name will

not be used in conjunction with any video or digital images.

Parent/Guardian signature___________________________________

Date: ________________________

Parent Release Form For Children/youth Media Recording