Name of Minor Child *

First Name

Last Name

Name of Parent/Guardian *

First Name

Last Name

Parent/Guardian Phone *

Country

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Model Release

For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I grant to Parents of Students of Phillips Academy, Incorporated (PSPA) and its assignees the unrestrained, irrevocable, worldwide and perpetual right to use my photograph and likeness, whether recorded on digital files, film or other media, publicly to promote the PSPA and the PSPA Campus Closet. I understand that my photograph and likeness may be used in print publications, online publications, websites, and/or social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. PSPA and its assignees have complete interest and ownership of my photograph and all copyrights to same, and I acknowledge that I have no interest or ownership in my photograph. I expressly release and indemnify PSPA and its members, officers, directors, employees, representatives, successors and assigns from any and all claims, known and unknown, arising out of or in any way connected with the above granted rights, uses and representations. I hereby certify that I am the parent or legal guardian of the person named above, I have read the foregoing, understand its terms and stipulations and I give my consent without reservation to the foregoing on behalf of him or her.

I agree

Signature *

Please type full parent/guardian name to sign this form.

First Name

Last Name

Today's Date *

MM

DD

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