APPENDIX B2
PHOTOGRAPH, MEDIA AND VIDEO AUTHORIZATION RELEASE FORM
I/We, (“Parent/Guardian”), as parent(s) or legal
guardian(s) of , give permission for _______________________
Chapter of Delta Sigma Theta Sorority, Incorporated (the “Chapter”) to publish on the Internet or media
still photographs or moving images, including, if applicable any sound recordings accompanying the
images (“Images”) taken of my child during participation in Youth
Initiative Program activities, without payment or any consideration and without notifying me in advance.
I/We also give permission for the Chapter to highlight my child’s achievements and activities in efforts to
promote the youth initiative program through newspapers, radio, TV, the web, DVDs, displays, brochures,
and other types of media without payment or any consideration and without notifying me.
I/We understand and agree that these Images will become the property of the Chapter, which shall have
complete ownership of the Images. I hereby irrevocably authorized the Chapter to publish or distribute
these Images for the purpose of publicizing the Chapter’s programs, including the
______________________________ Youth Initiative Program or for any other lawful purpose. In
addition, I waive any right to inspect or approve the finished product wherein my child’s likeness appears.
Additionally, I waive any rights to royalties or other compensation arising out of or related to the use of
the Images.
I/We hereby hold harmless and release and forever discharge the Chapter and any of its officers and
members; Delta Sigma Theta Sorority, Incorporated; its officers; National Executive Board; employees;
members; representatives; agents; and assigns from any and all claims, costs, suits, actions, judgments,
and expenses which my child, his/her heirs, representatives, executors, administrators, or any other
persons acting on his/her behalf have or may have by reason of the use of the Images. This release
specifically includes, without limitation, a complete release and discharge of any liability by virtue of any
editing, distortion, alteration, or optical illusion, whether intentional or otherwise, that may occur or be
produced in the taking of or editing of said Images, unless it can be shown that such was maliciously
caused, produced and published solely for the purpose of subjecting my child to conspicuous ridicule,
scandal, reproach, scorn and indignity.
I/we hereby certify that I/we are the parents/guardians of ,
authorized legally to give this consent, and do hereby give my/our consent without reservation to the
foregoing on behalf of my/our child.
____________________________________________ __________________________
Parent/Guardian Signature Date
____________________________________________
Print Name
____________________________________________ __________________________
Parent/Guardian Signature Date
____________________________________________
Print Name
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