Youth Story Media Release Form
Obtain permission to capture, use, and share a youth participant’s story media. This form is for parental/guardian consent for media collection and usage.
Youth Participant Full Name
*
First Name
Last Name
Youth Participant Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Youth Participant
*
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Type of Media Permission
*
Photo
Video
Audio
Written Story
All of the above
Where Media May Be Used
*
Website
Social Media
Print Materials
Presentations
Internal Communications
Parent/Guardian Signature
*
Submit
Submit
Should be Empty: