Parent/Guardian Name *

First Name

Last Name

Cell Phone #1 *

(###)

###

####

Cell Phone #2

(###)

###

####

Child's Name *

First Name

Last Name

Are you available to chaperone? *

Yes

No

Maybe

Photo/Video Release *

I hereby grant Episcopal Church of the Nativity permission to use my child's likeness in a photograph or video in any and all publications, including website entries, without payment or any other consideration. I further understand and agree that these materials shall become the property of Episcopal Church of the Nativity and will not be returned to me. I hereby authorize Episcopal Church of the Nativity to edit, alter, copy, exhibit, publish or distribute such photo or video for purposes of publicizing Episcopal Church of the Nativity programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my child's likeness appears. I waive any right to royalties or other compensation arising or related to the use of such photograph or video.

Yes

No