Challenger Learning Center of Lake Erie West

MEDIA RELEASE FORM

I, ____________________________________, hereby	DO or	DO NOT give permission for (Parent, Guardian, or Self) (Please print)

daughter/son/ward/self, _____________________________________________________ ( Print full name)

attending _______________________________________________________________ (Print school/organization name)

to appear in promotional photos, films, videos, web site or other media sponsored by the Challenger Learning Center of Lake Erie West to be taken at the CLC and other locations at the Shuer Center.	I understand that participation in this event is purely voluntary and without compensation, and that all material and images from this photo/film/video session(s) or other media will be owned solely by the Challenger Learning Center of Lake Erie West. I hereby give permission to CLC to use, display, license, sell, publish, etc. the images taken of me/my child for all purposes, including those of advertising and trade for CLC.

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Signature ( Parent, Guardian or Self)

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Date

Release of Liability

I release the Challenger Learning Center of Lake Erie West from any and all liability for property, damage, theft, or personal injury to my child/ward/self during or by reason of this activity. I authorize those in charge to furnish reasonable emergency treatment during this activity for my child for which I will be responsible. Please provide the Challenger Learning Center of Lake Erie West with an emergency phone number in case your child requires additional treatment.

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Signature (Parent, Guardian, or Self)

____________________________________________ Emergency Contact Name

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Date

________________________ Phone Number

Challenger Learning Center of Lake Erie West 2017