I hereby grant to the Community College of Allegheny County and those acting under its permission
or upon its authority, the irrevocable and unrestricted right to use and publish photographic and/or
video images, reproductions or likenesses of me/of my child* taken or recorded this day for use in
publications referencing or related to the college. In addition, I grant my permission to alter the
same without restriction; and to copyright the same.
This authorization and release covers the use of said photographic and/or video material, inclusive
of voice recordings as may be applicable, in any published form and medium of advertising or
publicity for an unlimited period of time.
This consent and release represents in full all the terms and considerations, and no other
inducements, statements or promises have been made to me/my child, nor have I been offered or
accepted any remuneration for my/my child’s voluntary participation.
Name (please print):
Email:
Telephone number:
Location of photo session:
Signature:
Date:
*Form must be completed by parent or legal guardian if individual is younger than 18 years of age
Child’s Name:
Signature of Parent/Guardian (if individual is under 18):
Date:
FOR CCAC USE ONLY
Image Name:
Upload Date:
Photographer:
Shoot Date:
Categories:
Revised 11.10.11
PHOTOGRAPHIC/VIDEO
CONSENT RELEASE FORM
Print
Allegheny Campus
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