Sample Photo Consent Form

I, ____________________________________________________ (Parent/Guardian Name), give consent to Tri-M Chapter #[chapter number] at [school name], or any party authorized by Tri-M Chapter # [chapter number] at [school name], to use (circle one) my son's/my daughter's photograph taken in connection with____________________________ (name of event) on______________ (date) at______________________ (location) for any Tri-M purpose including, but not limited to, use in publications (periodicals, books, brochures, etc.), video and audio productions, advertising and promotional materials, or other media.

I release Tri-M Chapter # [chapter number] at [school name], from any and all liability that may arise in connection with such use.

I am the parent or legal guardian of the child named below and have the legal authority to execute this consent and release.

Signature of Parent/Guardian:____________________________________________________
Relationship to Child:___________________________________________________________
Child's Name:________________________________________________________________
Date of Signature:_____________________________________________________________