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Parent Release Form for Media Recording

I, the undersigned, do hereby grant or deny permissi= on to Yellow Frame Presbyterian Church to use the image of my child,= , as marked by my select= ion(s) below. Such use includes the display, distribution, publication, transmissi= on, or otherwise use of photographs, images, and/or video taken of my child for= use in materials that include, but may not be limited to, printed materials suc= h as brochures and newsletters, videos, and digital images such as those on the = Yellow Frame Presbyterian Church Web site.

q   Deny permission to use my child’s image at all= .

q   Grant permission to use my child’s image in the following ways (mark all that apply):

q&nb= sp; Limited usage: I want my child’s image without their name used within<= /u> the Yellow Frame Presbyterian Church setting only (not in the larger community)= .

q&nb= sp; Limited usage: I want my child’s image without their name used on prin= ted materials only (no digital or video use).

q&nb= sp; Unrestricted usage: I give unrestricted permission for my child’s image and na= me to be used in print, video, and digital media. I agree that these images may be used by Yellow Frame Presbyterian Church for a variety of purposes and that these images may be used without further notifying me.

Parent/guardian signature____________________________= _____       Date_________________

Please make a copy of this form for your own r= ecords and mail or fax the original to:

Yellow= Frame Presbyterian Church

1 Yellow Frame Road
Newton, NJ 07860
Fax (973) 383-5652

 <= /p>

If you have questions, contact Yellow Frame Pre= sbyterian Church at Phone (973) 383-5364.

 =

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