Release Form

I_______________ give permission to YouMedia Portland and the Bell Whittington

Public library to use audio and visual recordings of myself and/or child (under the
age of 18)______________________. I understand a copy of these videos will be given
to my student, and I will be notified before their usage. I understand that these
videos are for educational and promotional purposes. I understand other YouMedia
students may use this footage. I understand that YouMedia will not accept any form
of compensation for any of the students videos.
If you have any further requests or changes please state here:
__________________________________
_____________________________________________________________________________________
Participants Printed Name:______________________ Participants
Signature:______________________
Guardians Printed Name:______________________ Guardians
Signature:________________________
Date Signed:__-__-____

[Type text]
Funded by the US Institute of museum and library services through a grant to the Texas state library and archives commission