Permission and Release Form for Enloe’s 2009 Baby Rascal Contest
PLEASE MAIL THIS COMPLETED FORM WITH PHOTO BY AUG. 19, 2009 TO: Trudy Duisenberg/Marketing & Communications Enloe Medical Center 1531 Esplanade Chico, CA 95926 OR E-MAIL THIS COMPLETD FORM WITH PHOTO BY AUG. 19, 2009 TO: trudy.duisenberg@enloe.org
Information about child in photo submitted for the Baby Rascal Contest
Name of Child: Birth Date of Child: The undersigned hereby grants to Enloe Medical Center the use of the photograph submitted of my child as a contestant in the 2009 Enloe Baby Rascal Contest for marketing, communications, promotional and charitable purposes as it may deem appropriate. The “photograph,” as used in this agreement, shall mean still photography in any format, as well as videotape, video disc, digital, electronic or other mechanical means of recording and reproducing images. We verify that the submitted image has not been taken by a professional photographer. As parents of , we do not expect to receive any financial compensation from Enloe Medical Center or
the Chico Outlaws in return for use of this image. This permission shall remain in effect for twenty-four (24) months from dated signature below. We represent that we are the parent/legal guardian of and hereby grant our permission to use and
distribute the submitted photo of our child. This form must be signed by both legal parents. Mother’s Info Print Name: Signature: ______________________ Date: Street Address: City: Phone: Father’s Info Print Name: Signature: ______________________ Date: Street Address: City: Phone: