C ALIFORNIA A RTS C OUNCIL ARNOLD SCHWARZENEGGER, GOVERNOR
CELEBRATING 30 YEARS OF EXCELLENCE IN THE ARTS MURIEL JOHNSON, DIRECTOR
The California Arts Council
California Poetry Out Loud
STUDENT PHOTO RELEASE FORM
I do hereby authorize the CALIFORNIA ARTS COUNCIL, and those acting pursuant to its
Record my participation and appearance on video tape, audio tape, film, photograph
or any other medium concerning my participation in the Program listed below.
Use my name, likeness, voice and biographical material in connection with these
Exhibit or distribute such recording in whole or in part without restrictions or
limitation for any educational or promotional purpose which the California Arts
Council, and those acting pursuant to its authority, deem appropriate.
EVENT: California Poetry Out Loud _____________________________
Student Name: _________________________________________________
School Name: __________________________________________________
School Address: _________________________________________________
Student Contact/Phone #.: __________________________________________
Student Email: __________________________________________________
Parent Email: ___________________________________________________
Student Signature: _________________________________________
Signature (if under 18): ______________________________________
Please fax your completed form to Kristin Margolis at (916) 322-6575.
Email photographs to email@example.com and firstname.lastname@example.org
1300 I STREET, SUITE 930 SACRAMENTO, CA 95814 (916) 322-6555 FAX (16) 322-6575 WWW.CAC.CA.GOV