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					Building Bridges Mentoring Program Washington County Youth Bureau
County Municipal Center 383 Broadway Fort Edward, New York 12828

Program Coordinator: Tammy Jursza (518) 746-2317

Model/Photograph Release Form
I, _______________________, give the Building Bridges Mentoring Program of the Washington County Youth Bureau the right to use my name (or any fictional name), picture, portrait, photograph and/or video image in any forms or media (including websites) for advertisement, recruitment and promotional/ PR tools in association with the Youth Bureau and Mentoring Program.

Signature: Date:

______________________________________ ___________________

Adult consent (if under 18)……………………….

I am the parent or guardian of the minor named above and have the legal authority to sign on behalf, giving approval of release of said items listed above.

Parent/Guardian Signature:

_________________________________________

Date: __________________________

Address:

http://www.co.washington.ny.us


				
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