Adult Release and Minor Consent Form for Media Recording

Adult Release and Minor Consent Form for Media Recording
I, the undersigned, do hereby consent and agree that Lake Washington United Methodist Church, its
employees, or agents have the right to take photographs, videotape, or digital recordings of me or my
children exclusively for the purpose of ministry within or promotion of or within the Lake Washington
United Methodist Church, and to use these in:
______Church Publications
______Church Bulletin Boards
______Worship Services or Events
______LWUMC Website (names always withheld)
______LWUMC Facebook pages (names always withheld)
I understand that there will be no financial or other remuneration for recording me or my children, for
either initial or subsequent transmission or playback.
I represent that I am at least 18 years of age, have read and understand the foregoing statement, and
am competent to execute this agreement. I give unrestricted permission for my child’s image to be used
in print, video, and digital media. I agree that these images may be used by for a variety of purposes and
that these images may be used without further notifying me. I do understand that the child’s name will
not be used in conjunction with any video or digital images on the internet. I further represent that I am
legally authorized to grant or withhold consent for the minor children listed below.
This agreement is valid until I rescind it.
______I deny permission to use my image or my children’s image at all.
______I grant permission to use my image or my children’s image as checked off above.
Children’s names: _____________________________________________________________________
Parent/ Guardian Name (print): __________________________________________________________
E-mail: ____________________________________________________ Phone: ___________________
Signature _________________________________________________ Date: ____________________