Sample: Photo Consent And Release Form


Sample: Photo Consent and Release Form
Following is a sample photo release you may consider if your school does not already provide one. This version is
developed for a minor, but could be adapted to use as an adult photo release as well.
I, ____________________________________________________ (Parent/Guardian Name), give consent
to Tri-M Chapter # [chapter number] at [school name], or any party authorized by Tri-M Chapter #
[chapter number] at [school name], to use (circle one) my son’s/my daughter’s photograph taken in
connection with______________________________ (name of event) on______________ (date)
at______________________ (location) for any Tri-M purpose including, but not limited to, use in
publications (periodicals, books, brochures, etc.), video and audio productions, advertising and
promotional materials, or other media.
I release Tri-M Chapter # [chapter number] at [school name], from any and all liability that may arise in
connection with such use.
I am the parent or legal guardian of the child named below and have the legal authority to execute this
consent and release.
Signature of Parent/Guardian:_________________________________________________
Relationship to Child:_______________________________________________________
Child’s Name:_ ____________________________________________________________
Date of Signature:__________________________________________________________


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