Photo & Video Release Form

I, the parent or legal guardian of acknowledge EmpowerMovement Education's use of photographs or videos taken throughout the course of the program for any legal use, relating to the program only, including but not limited to; publicity, copyright purposes, advertising, and social media use relating to the program only. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Check yes or no if you grant permission for your child to be included in photos or videos during the program.

Yes

No

Parent or Legal Guardian Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's School Name

Child's Teacher

Date

MM

DD

YYYY

Photo & Video Release Form

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