MEDIA RELEASE FORM
Together
Building Bridges
U.C.C. New
England WomenÕs
Celebration
VIII
March 12-14,
2010
To be signed by all
adult and youth participants; please bring to the meeting.
I give the U.C.C. New England WomenÕs Celebration VIII and its agents my permission to take my picture and/or videotape my participation in the Together Building Bridges using video and/or digital still camera. I understand that such video and photographs will be used for the purpose of sharing my participation and perspectives with a broader audience within the United Church of Christ. No promises have been made to me in exchange of my signature on this release. I have read this release form and understand the meaning of it.
____________________________________________________________________
NAME (please print)
___________________________________________________________________
ADDRESS
___________________________________________________________________
CITY STATE ZIP
___________________________________________________________________
(AREA CODE) PHONE SIGNATURE DATE
If the participant is under the age of eighteen:
I am the parent/guardian of ______________________________________________
(Please print name of child)
who is a youth under the age of eighteen. I grant permission for my child to be included in media used at this event by the U.C.C New England WomenÕs Celebration VIII
____________________________________________________________________
SIGNATURE OF PARENT OR GUARDIAN DATE