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AUDIO/VIDEO/PHOTOGRAPHIC USE AUTHORIZATION AND RELEASE

I authorize Communities In Schools of Houston, Inc. (“CIS”) and its affiliates, employees, contractors, representatives, and agents, as well as media and other organizations that are working or collaborating with CIS, to take or create photographs, audio and video recordings, and other images of (“Participant”).


I agree that CIS may use and permit other persons and entities to use photographs, audio and video recordings, and other images of Participant without restriction in such manner as is deemed necessary or appropriate, including, but not limited to, dissemination for educational,  research,  scientific,  public  relations,  community  affairs,  fundraising, marketing, or charitable purposes, and that dissemination may be accomplished in any manner, including, but not limited to, newspapers, radio, TV, the Internet, social media, DVDs, displays, billboards, brochures, and other types of media.


I, on behalf of myself, my family members, and our beneficiaries, heirs, executors, administrators, successors, assigns, representatives, and agents, release CIS and its Board of Directors, employees, representatives, agents, successors, and assigns from any and all claims and liabilities, known or unknown, arising from or in any way related to the taking, creation, use, publication, distribution, or reprinting of photographs, audio or video recordings, or other images of Participant.



I understand and agree that this release includes any and all claims for compensation of any kind as a result of the taking, creation, use, publication, distribution, or reprinting of photographs, audio or video recordings, or other images of Participant. I also understand that I may not withdraw my agreement to this authorization and release.


I have read this authorization and release and fully understand its terms and conditions. I represent that I have the right, capacity, and authority to execute this authorization and release and do so voluntarily.


Please select who will be participating...
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First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Address Line 1
Address Line 2
City
State
Zip code
First Participant's Signature*
Guardian's Email Address
Email*
Confirm Email*
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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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Guardian's Date of Birth*
Date of Birth
Guardian's Information
Address Line 1
Address Line 2
City
State
Zip code
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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