Video Release Form for Minors/Adults
I hereby give my permission, as the parent/legal guardian of the participating student named below, to the Washington State Office of the Superintendent of Public Instruction for the use and reproduction of the video footage, photographs or voice recordings of this participating student. I understand that the use of the participant's image and voice will be primarily for the purposes of education and/or promotion by the Washington State Office of the Superintendent of Public Instruction programs. Students last names will not used in an audio or video production without additional authorization from a parent. The signature below indicates my permission for the Washington State Office of the Superintendent of Public Instruction to use video footage recorded for the project described below. Video footage filmed during meetings and/or activities of The Legislative Youth Advisory Council and for which (student name) ____________________________ served as a participant. This video footage may be used for the following purposes: Conference presentations Educational presentations Informational presentations Educational television broadcast Video clip on a Washington State Office of the Superintendent of Public Instruction (or affiliated) web site I will be consulted about the use of the video recording for any purpose other than those listed above. There is no time-limit on the validity of this release nor is there any geographic specification of where these materials may be distributed. This release applies to video footage collected as part of the project(s) listed on this document only. I have received a copy of this release form. For Minors: Student Name (please print name) ____________________________________________ Parent/Legal Guardian (please print name) _____________________________________ Parent/Legal Guardian Signature: ____________________________________________ Address: ________________________________________________________________ Phone: ________________________________________________________________ For Adults 18 and Over: Student Name (please print name) ____________________________________________ Student Signature: ________________________________________________________ Address: ________________________________________________________________ Phone:_______________________________________________________________