NAME OF PARENT/GUARDIAN
GRANTING PERMISSION:
ADDRESS:
PHONE:
EMAIL:
EVENT/CLASS TITLE:
I, __________________________________, hereby agree that the District Board of Trustees of Palm Beach State College
(the “College”), and those acting pursuant to its authority, shall have the right to record the participation, appearance,
likeness and voice on videotape, audiotape, photograph, digital, electronic or in any other medium of the minor or adult
dependent listed above and I hereby unconditionally and irrevocably consent to the College’s use of such materials for any
legal purpose the College deems appropriate for the benefit of the College, including commercial and advertising purpose
also, I hereby forever waive (i) any right to require payment from the College for the use of these materials by it or those
acting pursuant to the College authority and (ii) the right to object to the use of such materials for any purpose permitted by
this Consent and Release, including, without limitation, the license or sale of such materials by the College and those acting
pursuant to its authority who publish, print, display, exhibit, distribute or otherwise publicly use any such materials for any
legal purposes. I understand the foregoing consent and release grants the College the right to edit, crop, retouch, or
otherwise reasonably alter such materials, at its discretion, and, at its option, to reveal my name and identity in such materials
or by descriptive text or commentary. I understand and agree that any intellectual property rights associated with such
materials are the sole property of the College. Furthermore, I agree that this release shall be construed in accordance with
the laws of the State of Florida and if any term or provision of this release shall be held illegal, unenforceable, or in conflict
with any law governing this release, the validity or enforceability of the remaining portions shall not in any way be affected
or impaired thereby. I hereby warrant that I am a legal competent adult and a parent or legally appointed guardian of the
minor, and that I have every right to contract for the minor in the above regard.
SIGNATURE (required): ____________________________________________ DATE: _________________________
CRM_ModelReleaseMinor_02052018_KF
Please fill out completely and sign/date at the bottom.
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