Photography Release Form for Minor Child or Children

I/We, the parent(s) and/or guardian(s) listed below (“Authorizer”), authorize Nancy L. Smolinski d/b/a Children’s Piano Institute, LLC (“Company”) to publish photographs of the minor child and/or children listed below (“Child”), and their names and likenesses (“Materials”), for use in the Children’s Piano Institute, LLC’s print, online and video-based marketing materials, as well as other Company publications.

This Release and the use of the Materials shall be continuing. Authorizer shall be required to submit to Company a written request to rescind this Release. Company shall be granted a minimum of one-year for use of the Materials during which no rescission of this Release may occur. Company shall be permitted the continuing use of any printed, video-based or other materials, even after a rescission has occurred, until such materials have been exhausted. Company shall have Ninety (90) days after any rescission to remove photographs in use on any electronic media such as a website.

The Authorizer hereby releases and holds harmless Children’s Piano Institute, LLC and Nancy L. Smolinski from any reasonable expectation of privacy or confidentiality for the Child associated with the images specified above. Further, the Authorizer attests that he/she/they are the parent(s) or legal guardian(s) of the Child and that the Authorizer has full authority to consent and authorize Nancy L. Smolinski d/b/a Children’s Piano Institute, LLC to use the Child’s likenesses and names.

The Authorizer further acknowledges that participation is voluntary and that neither the Authorizer nor the Child will receive financial compensation of any type associated with the taking or publication of these photographs or participation in Company marketing materials or other Company publications. The Authorizer acknowledges and agrees that publication of said photos confers no rights of ownership or royalties whatsoever to Authorizer or Child.

The Authorizer hereby releases Children’s Piano Institute, LLC and Nancy L. Smolinski, their contractors, employees and any third parties involved in the creation or publication of Company publications, from liability for any claims by the Authorizer, the Child or any third party in connection with the participation of the Child.

Download PDF

Authorization of Parent(s) and/or Guardian(s):
Date*
MM slash DD slash YYYY
Parent/Guardian 1 Name*
First Last
Parent/Guardian 1 Relationship To Children*
Parent/Guardian 1 Email*
Parent/Guardian 1 Phone*
Parent/Guardian 1 Signature*
Parent/Guardian 2 Name
First Last
Parent/Guardian 2 Relationship To Children
Parent/Guardian 2 Email
Parent/Guardian 2 Phone
Parent/Guardian 2 Signature
Address*
Street Address Address Line 2 City State ZIP Code
Names and Ages of Minor Children:
Child 1 Name*
First Last
Child 1 Age
Child 2 Name*
First Last
Child 2 Age
Child 3 Name*
First Last
Child 3 Age
Phone
This field is for validation purposes and should be left unchanged.

Prepared by the Law Offices of Bingaman, Hess, Coblentz & Bell, P.C.

Review Cart

Cart is empty

Photography Release Form for Minor Child or Children

Authorization of Parent(s) and/or Guardian(s):

Names and Ages of Minor Children: