Electronic Photo and Media Consent and Release Form

Parent / Guardian Name:

Student Name:

Email:

Phone:

I, as a parent choose:

I agree that St. Vincent de Paul Parish, and/or Diocese of Fort Wayne - South Bend may use photographs, video or other media of my child for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising and Web content.

No, I do not grant St. Vincent de Paul Parish the right to take photographs and publish, video or other media of my child.

Parent / Guardian Signature

Date Signed

Photo & Media Consent and Release Form

Contact Info