Visual/Audio Release Form
Gaurdian’s First Name Gaurdian’s Last Name Signature of parent/guardian
Email Date Telephone
By signing above, you acknowledge that you are the legal parent/guardian of the above named child and that you have read and understand the terms of this release. This information is kept
confidential. The University will not sell photo/video footage to any third party. Images are protected under copyright of Lesley University.
Date of Shoot Location ☐ Photography ☐ Videography For Internal Use Only
As a parent/legal guardian of , I hereby grant permission to Lesley University, to
use my child’s image, representations of his/her audio and/or visual works, and his/her verbal and written statements for promotional purposes in
University publications, advertising, video, web, social media, or other formats. The images may be used now or in the future without notifying me.
I understand that I waive any right to inspect or approve the finished images or any printed or electronic materials and that Lesley University does
not owe me any compensation for their use.
please print child’s full name
Email completed form to firstname.lastname@example.org
Lesley University Office of Communications and Marketing
29 Everett Street, Cambridge, MA 02138
email@example.com ◆ lesley.edu