Real Talk :: Release Form

Child(ren)'s Full Name(s) *

I acknowledge that I am the parent/legal guardian of this teen/these teens. *

Yes

I agree to allow my child(ren) to be photographed &/or videotaped. *

Yes

I agree that the image(s) may be used to promote the work of Alliance for Positive Health's REAL Talk teen program. *

Yes

I understand that the photos/images taken of my child belong to Alliance for Positive Health. *

Yes

I understand I will not receive any compensation for the use or distribution of the photos/videos. *

Yes

I understand that by my child(ren) appearing in these photos/images they may be perceived as receiving services from Alliance for Positive Health. *

Yes

I give my permission to Alliance for Positive Health to use and distribute my child(ren)’s photograph whether still, motion, or television in any legal manner whatsoever. *

Yes

I understand a staff person will contact me to verify that I am the parent/guardian of the above named child(ren) and give my permission for my child(ren) to be photographed. *

Yes

I agree to hold harmless Alliance for Positive Health including its employees, volunteers, and agents, all sponsoring organizations, and any other parties connected to this organization/event in any way, singly or collectively, from and against any claim or liability for any injury, misadventure, harm, loss, inconvenience, or damage hereby suffered or sustained as a result of Alliance for Positive Health’s use or distribution of my photo or recorded image or any activities associated herewith, whether or not caused by the fault or negligence of any of them. *

Yes

I hereby give my permission to Alliance for Positive Health, its successors or assigns, to use and distribute my photograph whether still, motion, or television in any legal manner whatsoever. *

Yes

Parent/Guardian’s Name *

Phone number where parent/guardian can be reached *

Parent/Guardian Email Address

Today's Date *

I agree to all the terms listed in this form. *

Yes

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