Participant & Parent(S)/Guardian(S) Form

Media Release Form

Because both GLSEN and the media need release papers allowing the use of your and/or your child’s voice, image, comments or ideas, the following has been developed by GLSEN to serve all of these needs in one simple form. Please provide your personal information below and read/sign the Media Release section at the bottom, verifying that you consent to the use of your and/or your child’s image, voice, comments and/or ideas by GLSEN and approved media outlets.

Name Email

Address: City State

Phone: Date of Birth (if under 18)

Media Agreement

Terms Used:

“Footage” – refers to all video, audio or written material of Participant.

“Guardian” – refers to the legal parent(s) or legal guardian(s) of the Participant, under the age of 18 years old.

“Participant” – refers to the person in question.

“Media” – refers to GLSEN and each of the GLSEN-approved media, advertisers, and sponsors.

“Ze” – refers to a non-gender-specific or gender-neutral pronoun.

This Release is made this day of (month), (year), by

(participant) and (guardian, if under 18)

in favor of GLSEN and media, in conjunction with the 2013 Media and Safe Schools Summit.

Participant hereby represents that he/she/ze is (participant) and has the legal right to sign this release granting GLSEN and all Press permission as further provided herein.

If under 18 years of age:

Guardian hereby represents that he/she/ze is the legal guardian of (participant) and has the legal right to sign this Release.

Participant/Guardian herby grants media the irrevocable, unconditional and unrestricted right to photograph, record, videotape and/or interview participant and to use, publish, broadcast, and publicly display participant’s name, voice, likeness, biographical information, and any or all of the footage in any of media’s programming, publications, or the promotion thereof. In addition, Participant/Guardian agrees that the rights granted hereunder shall include the perpetual, worldwide right of media and its parent, subsidiaries, and affiliated companies to edit, telecast, cablecast, rerun, record, publish, reproduce, use, syndicate, license, print and/or distribute for any purpose, in any manner and in any medium or forum – whether now known or hereafter devised – the footage, or any portion thereof without payment of consideration.