Annual Project Voice: A Dynamic Approach to Youth Empowerment

PERMISSION SLIP
Youth Name: ________________________________________________ Age: _________ Address: __________________________________________________________________ City: ________________________________ State: _____ Zip: __________ Phone: ________________________ Email: _____________________________________

MEDIA RELEASE
Please tell us whether you are willing to be quoted and to permit us to use photographs that may be taken of you in publications or releases made by the School-Community Health Alliance of Michigan (SCHA -MI). We will identify you by first name only, with your age and city of residence. If you do not want photos of you to be used and you do not want to be quoted, please indicate below and we will not use any images of or direct quotes from you. Yes, the event organizers may quote me and use photographs of me in publications or releases made by SCHA -MI. No, I prefer not to be quoted and do not want the event organizers to use photographs of me. Students Signature _______________________________ Date _____________ Signature _______________________________________ (parent or legal guardian) Date _____________