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: _ _________________________________