New Haven County Bar Association
171 Orange street
New Haven, CT 06506-1441
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Tel (203) 562-9652 Fax (203) 624-8695
Law Camp for Teens
Summer 2017 Application
Name of Student: ______
Address: ______
______
Phone: Gender: ______T-shirt size:_____
Date of Birth:______Age at time of Law Camp:______
Current School: ______
Grade Entering Fall 2017: ______
Describe your ethnic origin (optional): ______
Name of Guardian: ______Phone Number: ______
Name of Additional Emergency Contact: ______
Phone Number: ______
How did you hear about Law Camp?
______
Do you have access to transportation outside New Haven? ______
Why would you like to attend?
______
______
New Haven County Bar Association
171 Orange street, P.O. Box 1441
New Haven, CT 06506-1441
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Tel (203) 562-9652 Fax (203) 624-8695
PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE
FOR MINORS
NAME OF MINOR: ______
(Last) (First) (Middle)
NAME OF PARENT/GUARDIAN:______
Address:______
City: ______State: ______Zip code: ______
Phone: ( _____ ) ______E-mail:______
I hereby grant permission to New Haven County Bar Association (NHCBA) & The Foundation of the New Haven County Bar(FNHCB) to use, including to display publicly or to perform, the above-named minor’s image, likeness, or voice recording on the NHCBA & FNHCB website or in any other official NHCBA & FNHCB publications without further notice or compensation. I hereby consent that any such image, likeness, or voice contained in photographs, recordings, and tapes are the property of NHCBA & FNHCB, which shall have the right to print, reprint, publish, copy, vend, perform or represent publicly, or create derivative works based on and using the image, likeness, or voice depicted in such photograph, film, or sound recording as it may desire free and clear of any claim whatsoever on my part or the part of the above-named minor.
I also understand that once the above-named minor’s image, likeness, or voice recording is published on a web site, it can be downloaded by any computer user. Personal information, such as a minor’s full name, parent/guardian’s names, addresses and telephone number will never be published. If a minor’s name is used with a photograph, film, or sound recording, it will be in the form of a first name and last initial. For example, student Jane Doe may be listed as “Jane D.”
Therefore I agree to indemnify, defend and hold harmless NHCBA & FNHCB its officers, employees, agents, successors and assignees (the “Indemnified Parties”) from and against any and all claims and liabilities resulting from this publishing.
Permission is granted for the use requested above.
SIGNATURE: ______DATE: ______
(Parent or Guardian)
OR
Permission is denied for the use requested above.
SIGNATURE: ______DATE: ______