Media Release Form

HomeMedia Release Form

Media Release Form

I hereby grant the Charlevoix Public Library the right to obtain and/or use the following for educational and informational purposes. I understand that such media and all subsequent uses of that media, including publications, presentations, web sites, videos and multimedia productions, become the property of the Charlevoix Public Library and may be disseminated to the public via appropriate media channels. I understand that a photograph of my child appearing on the approved Charlevoix Public Library web site will not identify my child by name. The media release for anyone under the age of 18 must include the signature of a parent or guardian.

Please check all that apply:*
- My photograph, digitized image, video and/or voice recording
- My child’s photograph digitized image, video and/or voice recording
This release is for:
First Last
Please indicate if:*
- Adult
- Child
Parent/Guardian Name (Please Print)
First Last
Signature of Adult or Parent/Guardian
First Last
Date
Date Format: MM slash DD slash YYYY