PARENT/GUARDIAN RELEASE FOR STUDENT OR MINOR
(NONCOMMERCIAL)
This section to be completed by the Archdiocesan entity (school/parish/ACC) sponsoring the
activity (“Location”):
Name of Location: ________________________________________________________________________________________
The Location intends to use your child’s image, name, voice and/or work for noncommercial
purposes relating to the event(s) or activity(ies) identified below.
Description of events/activities to which this Release applies:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Duration of Release: _______________________________________________________________________________
This section to be completed by Parent/Guardian:
I, __________________________________________________________________________ am the parent/guardian of
_________________________________________________________ , a minor.
I hereby authorize the Location to use the following personal information about my child:
(Please initial the applicable boxes)
Image: yes no Voice: yes no Name: yes no Work: yes no
I understand and agree that my child’s image, voice, name and/or work (“Personal Information”)
relating to the events or activities described above will be used for noncommercial purposes,
including, but not limited to, publicity, exhibits, electronic media broadcasts or research. I
understand and agree that my child’s Personal Information may be copied, edited and distributed
by the Location in publications, catalogues, brochures, books, yearbooks, magazines, exhibits,
films, videotapes, CDs, DVDs, email messages, websites, or any other form now known or later
developed (“Materials”).
The Location may use the Personal Information at its sole discretion, with or without my child’s
name or with a fictitious name, and with accurate or fictitious biographical material. The Location
will not use the Personal Information for improper purposes or in a manner inconsistent with the
teachings of the Roman Catholic Church.
I waive any right to inspect or approve any Materials that may be created using the Personal
Information now and in the future. In exchange for the opportunity given to my child by the
Location to participate in the activity, I agree that neither I, nor my child, will receive monetary
compensation, royalties or credit. I understand and agree that the Location shall be the owner of
all right, title and interest, including copyright, in the photographs, electronic recordings and
Materials. If the Location intends to use the Materials for a commercial purpose, I will be provided
at that time with information about the terms of the commercial use.
I hereby waive, release and forever discharge any and all claims, demands, or causes of action
against the Location and its affiliated entities, employees, agents, contractors and any other
person, organization, or entity assisting them with the photography, electronic recording or
Materials, for damages or injuries in any way related to, or arising from the photography,
electronic recording or Materials, or the use of the Personal Information, and I expressly assume
the risk of any resulting injury or damage.
I further understand and agree that this Authorization remains in effect until it is withdrawn in
writing. I understand that if I change my mind about this Authorization, that I will submit another,
new authorization form to the Location. However, my new authorization will not have the effect
of revoking this Authorization, and the Location will have no duty or obligation to make any
changes or alterations to any Materials that may have been prepared based on this Authorization.
I represent that I have read this Authorization, understand the contents and am able to grant the
rights and waivers it contains. I understand that the terms of this Authorization are contractual
and not mere recitals. I am signing this document freely and voluntarily.
Signature: _________________________________________________________ Date: ________________________________
Print Name: _________________________________________________ Relationship to Child: __________________________
Address: __________________________________________________________________________________________________
Telephone: __________________________________________ Cellphone: _____________________________________________
Email: _____________________________________________________________________________________________________
Name of Child: ______________________________________________________________ Age: ________________________