Student's Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Student's Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

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Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

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Photo/Video Release *

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to IMAGINE! Youth Theatre (being a part of Lindsey Wilson College), its affiliates and agents, to use my child’s image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of my child and/or record my child’s voice; (b) Permission to use my child’s name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

I consent to the Photo/Video Release above

I do not consent to the Photo/Video Release above