Photography Consent Form - Child

Community Services Department
PHOTO RELEASE FORM
I
am the legal guardian of
and hereby -  - Authorize  - do not authorize
the City of Edmonton to use the name/image of the child named above in its public
relations and communication materials created for a period of two years from date
consent is signed. I realize that I may withdraw my consent in writing at any time by
contacting the
.
I understand that the photograph(s) may be used in a publication, print advertisement,
direct-mail piece, electronic media (e.g., video, CD-ROM, internet, World Wide Web,
Social Media, etc.) or other form of communication.
In giving my consent, I hereby release and hold harmless the Community Services
Department, the City of Edmonton and their agents, employees, officials,
representatives and contractors from any and all responsibility or liability for damage of
any kind suffered in any manner whatsoever.
I hereby relinquish any and all personal or proprietary rights I may have in connection
with such use. I understand that I will receive no compensation should any photograph
of me be used.
Date:
Witness:
Legal Guardian
Signature:
Child’s Signature:
This information is being collected under the Authority of Section 33(c) of the Freedom of
Information and Protection of Privacy (FOIP)Act and may be used for the administration of
Community Services Department programs, including public relations events. If you have any
questions about the collection, use and disclosure of this information please, contact the
.
Program Representative
Revised June 22, 2012