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Extreme Studio Performance – Verifiable Parental Consent

VERIFIABLE PARENTAL CONSENT FOR COLLECTION, USE, AND DISCLOSURE OF CHILD’S PERSONAL INFORMATION - READ BEFORE SIGNING

     I (“Parent/Guardian”) consent to photography and videotaping by Extreme Studio Performance (“ESP”) employees, and its/their release, publication, exhibition, or reproduction of (“Child” or “Minor Participant”) to be used for purposes including, but not limited to, public relations, news articles or telecasts, education, advertising, marketing, fund-raising, inclusion on ESP’s website, Facebook, and Instagram.

     Pursuant to the Children’s Online Privacy Protection Act (“COPPA”), ESP, located at 4435 McEwen Road, Dallas, Texas 75244, wishes to collect personal information from the Child. The “personal information” of the Child includes images, photographs, video recordings, and video tapings of the Child while participating in activities at ESP.  Parent/Guardian’s consent is required for the collection, use, and disclosure of the Child’s personal information. Parent/Guardian consents to ESP’s collection, use, and disclosure of the Child’s personal information by signing this document. Parent/Guardian has the option to consent to the collection and use of the Child’s personal information without consenting to disclosure of the Child’s personal information to third parties. Parent/Guardian’s failure to consent to ESP’s collection, use, and disclosure of the Child’s personal information will not prevent the Child from participating in activities on the ESP premises. ESP will not require a child to disclose more personal information than is reasonably necessary to participate in an activity as a condition of participation. Parent/Guardian can review the Child’s personal information, ask to have it deleted, and refuse to allow any further collection, use, or disclosure of the Child’s information. ESP has established and maintains reasonable procedures to protect the security and integrity of the personal information collected from the Child. If the Parent/Guardian does not wish to provide consent for ESP’s collection, use, and disclosure of the Child’s personal information, or seeks to revoke previously granted consent, Parent/Guardian must contact ESP at (214) 389-4001 (main number) and request to speak to Michael Scaccia, or by e-mail at info@espfit.net.

     Parent/Guardian releases ESP, its officers and employees, and each and all persons involved from any liability connected with the taking, recording, or publication of said photographs, videotapes, or computer images involving the Child. Parent/Guardian waives all rights he/she may have to any claims for payment or royalties in connection with any exhibition, televising, or other publication of these materials, regardless of the purpose or sponsoring of such exhibiting, broadcasting, or other publication. All negatives and positives, whether prints, film or video, are the property of ESP or the person or entity designated by it, solely and completely.

I HAVE READ THIS RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Date Signed: November 20, 2018

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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