(One per child.)
I, ________________________, hereby give the Archdiocese of Philadelphia, its
(Parent’s name)
successors and assignees and those acting with its authority, the unqualified right and permission to reproduce, copyright, publish, circulate or otherwise use any school pictures of my child produced by the Archdiocese of Philadelphia. This authorization and release covers the use of said school pictures in any published form and any media of advertising publicity.
I also understand that our school may be identified by name and I fully understand that this is a complete release of all claims against the Archdiocese of Philadelphia or any other person, firm or corporation by reason of any such use of such school pictures.
I hereby warrant that I am free to give this permission. I further warrant that the information I have provided is, to the best of my knowledge, true and accurate.
Signature of Parent(s)/Guardian(s) Date
Student’s Name Grade Date of Birth
Address
City, State, Zip
2009-2010
Phone School year