Parental Consent for Media Release
Please complete this form to authorize the use of your child's image, video, or audio for media or promotional purposes.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Guardian's Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent or Guardian's Email Address
*
example@example.com
Parent or Guardian's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
School or Organization Name (if applicable)
Type of Media to be Released
*
Photographs
Video Recordings
Audio Recordings
Other
Purpose of Media Use
*
Please Select
School Website/Social Media
Promotional Materials
Newsletters
Press Releases
Other
Signature of Parent or Guardian
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments (optional)
Submit Consent
Submit Consent
Should be Empty: