S.T.A.R. w/Teens Inc.
Photograph-Personal Information
Non Profit Organization Consent Release
Form
This consent form is
to inform you, and to request your permission for your child’s photo/image to
be used for STAR w/Teen’s publicity and promotional purposes.
Pursuant to law,
we will not release any personal information regarding your child other than
his or her name, without your written approval. Addresses, phone numbers, and
any other information will remain confidential among the team participating on
STAR projects, and will not be used for solicitation.
We/I understand
that our/my son, daughter, or my own photo, may be used for publication for
STAR w/Teens which is also accessible on the world-wide web. Photos shoots may be used in, and are not limited
to, brochures, pamphlets, and other forms of media that may be used to promote
STAR w/Teens in the future. We/I do understand that their name only may appear
on promotional material. No home address
or telephone number of you or your child will appear within any of the publications.
All photo/information release forms are to be kept on file at the STAR w/ Teens
office location for at least one calendar year.
Name of
Participant________________________________________ Date_________
Print name here
Signature of
Participant ____________________________________ Date_________
Signature here
Parent or
Guardian________________________________________ Date_________
Print name here
Signature of
Parent or Guardian ______________________________ Date_________
Signature here
I do not wish my picture or my child’s
picture to be used or posted for any of STAR w/Teen’s promotional publicity.
Name of
Participant__________________________________________ Date_________
Print name here
Signature of
Participant ______________________________________ Date_________
Signature here
Parent or
Guardian__________________________________________ Date_________
Print name here
Signature of
Parent or Guardian ________________________________ Date_________
Signature here