MEDIA/NEWSPAPER RELEASE FORM
Please initial the statement(s) below in which you agree:
____I authorize and grant permission to North Central Kansas Technical College, hereinafter known as the
“College”, and its affiliates and agents, to use my image, statements, photographs, videos, and/or voice
recordings for use in any and all electronic or print College communications or for use, or distribute for use, in
non-college publications, electronic or otherwise, at the College’s discretion. (and)
I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in
conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right
to royalties or other compensation arising from or related to the use of the image. (and)
I acknowledge that I have not been convicted of a criminal offense, nor do I have any pending criminal charges,
nor have I been accused or involved in any misconduct in my past that could have an adverse impact to the
College’s reputation if my image was used.
____I would like my achievements (this can include, honor roll, scholarships, awards, student organization
involvement, competitions, etc.) publicized in the newspaper. If you agree, please list the newspaper you would
like us to use.
Newspaper Name: City:
Student First Name:
Signature:
(If under 18
years of Age-parent or guardian signature required)
Student First Name:
Student LastName:
Student First Name: Student First Name: Student First Name: Student First Name: Student First Name: Student First Name:
Please enter your birth date in place of signature
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