Pine Mountain Settlement School
Policies and Procedures

RELEASE FOR USE OF IMAGES

I hereby give my consent to Pine Mountain Settlement School (PMSS) to photograph, film, videotape and then use, reproduce, and publish said images of me and/or my child/children.

Please print name:

____________________________________________________________________________________________

Please print child/children’s name(s):

__________________________________________________________________________________________

__________________________________________________________________________________________

I agree that photographs/negatives, film, or videotapes thereof shall constitute the sole property of Pine Mountain Settlement School, with full right of disposition in any manner whatsoever, including the right to publish on PMSS websites.

I hereby release PMSS and its legal representatives and assigns from any and all claims whatsoever in connection with the use, reproduction, publication of the images thereof.

Signature & Date:________________________________________________________________________________

Signature for minor child/children & Date:________________________________________________________

Title/Organization/School:_________________________________________________________________

Address___________________________________________________________________________________

___________________________________________________________________________________________

Phone________________________________________________________________________________________________

Email_________________________________________________________________________________________________

Source: Sample Photo Release Form, Google Docs, accessed 16 June 2015 aae. https://docs.google.com/document/d/1wmLKCuDhK2rdgGnvQIJAG7X37yzpNlh7J6v0hGogVTg/edit

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