EmailMeForm
YOUTH MEDIA CONSENT FORM
I, the parent or legal guardian of the youth named below, grant Genesis Community Development Corporation (Genesis CDC) permission to use photographs, video, and audio recordings of my child taken during program activities.
I understand these materials may be used for purposes such as:
* Grant applications and reporting
* Publicity and marketing
* Social media and website content
* Educational or informational resources
I further understand that:
Materials may appear in both print and digital formats.
No royalty, fee, or other compensation shall be payable to me or my child for the use of these materials.
Genesis CDC may use my child’s first name and last initial in connection with these materials, but will not publish full identifying information without additional consent.
By signing below, I release and hold harmless Genesis CDC, its officers, employees, and agents from any and all claims connected to the use of these images or recordings.
Parent/Guardian Information
Parent/Guardian’s Name
*
First
Last
Relationship to Youth
*
Date
*
MM
/
DD
/
YYYY
Signature
*
Clear
Use mouse or touch-pad
Youth Information
Youth’s Name
*
First
Last
Phone
###
-
###
-
####
optional
Age
*
Email Address
optional
