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Model   R elease   F orm  
You   h ave   b een   i nvited   t o   p articipate   i n   a   y oung   w omen’s   e mpowerment   c onference,   “ Girl   C ode,”  
sponsored   b y   t he   I nstitute   f or   C reative   C ommunity   I nitiatives.   " Girl   C ode"   c onferences   b ring   " tween"   a nd  
teen   g irls   o f   t he   G reater   W ashington   m etropolitan   a rea   t ogether   t o   a ddress   i mportant   i ssues   a nd   r eceive  
empowering   m essages   f rom   t heir   p eers   a nd   i nfluential   c ommunity   l eaders.   T hey   a fford   d iverse   g roups   o f  
young   w omen   a n   e xcellent   o pportunity   t o   p ractice   l eadership   a nd   c ommunication   s kills   i n   d iscussions   a nd  
activities   f ocused   o n   i ssues   c ommonly   f aced   d uring   a dolescence.    
We   h ave   t wo   g oals   i n   m ind   a s   w e   p lan   “ Girl   C ode”   c onferences   i n   c ollaboration   w ith   o ur   y outh  
coordinators   -­‐   ( 1)   t o   p romote   s elf-­‐love   i n   t eenage   g irls,   a nd   ( 2)   t o   e ncourage   y oung   w omen   t o   m ake  
informed,   h ealthy   d ecisions.   T he   p urpose   o f   t his   c onference   i s   t o   b uild   a   c ommunity   o f   s elf-­‐confident,  
well-­‐informed   y oung   w omen   t o   s erve   a s   a   k nowledge   b ase   a nd   s upport   s ystem   f or   t heir   p eers.   W e   k now  
it   i sn’t   e asy   b eing   a   g irl   a nd   w ill   p rovide   y oung   w omen   w ith   i nformation   a nd   r esources   t hat   w ill   h elp   t hem  
successfully   n avigate   t heir   t eenage   y ears   a nd   b eyond.    
Your   p articipation   w ill   t ruly   e nhance   t his   e xperience.   W e   a sk   t hat   y ou   p rovide   y our   w ritten   c onsent  
allowing   y ourself   t o   b e   p hotographed/video   r ecorded.   F eel   f ree   t o   c ontact   t he   I CCI   P roject   M anager,  
Emily   W ilson,   a t   ( 301)   5 52-­‐8803   o r   e   i f   y ou   h ave   a ny   q uestions   o r   c oncerns.  
Thank   y ou   i n   a dvance   f or   y our   s upport.  
Please   c omplete   t he   b ottom   h alf   o f   t his   f orm.  
Please   c ircle   “ AM”   o r   “ AM   N OT.”  
I     A M   /   A M   N OT   w illing   t o   a ppear   i n   p hotographs/video   r ecordings   t ake   a t   “ Girl   C ode.”   I   a m   a ware   t hat  
these   p hotographs/video   r ecordings   m ay   b e   u sed   o n   I CCI’s   w ebsite,   s ocial   m edia   p ages,   p romotional  
materials,   a nd/or   i n   t he   p ress.  
 
Name:   _ _________________________________          
Signature:   _ ______________________________  
Date:     _ _________________________________  
Phone   N umber:   _ ______________________________   E mail:   _ _________________________________  
 
 

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