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St. Jude Catholic Church
Minor/Student Release Form
(age 15-17)
Revised: 17 September 2001
St. Jude Parish, Fort Wayne, Indiana
Publications, Video, Internet Consent and Release Agreement
Minors/Students associated with St. Jude Catholic Church
are occasionally asked to be a part of youth ministry publicity, publications and/or
public relations activities. In order to guarantee student privacy and ensure your
agreement for your student to participate, St. Jude Catholic Church asks that you sign
this form and return it to the parish office for each of your students age 15-17.
The form referenced below indicates approval for the
student's name, picture, art, written work, voice, verbal statements or portraits (video
or still) to appear in school publicity or St. Jude Parish publications, videos or on the
parish web site. For example, pictures and articles about youth ministry activities may
appear in local newspapers or district publications. These pictures and articles may or
may not personally identify the student. The pictures and/or videos may be used by the
parish in subsequent years.
AGREEMENT
Student and Parent/Guardian release to St. Jude Catholic Church the student's name, picture, art, written work, voice, verbal statements,Student and Parent/Guardian release to St. Jude Catholic Church the student's name, picture, art, written work, voice, verbal statements,
portraits (video or still) and consent to their use by St. Jude Catholic Church.
St. Jude Catholic Church agrees that the student's name,
picture, art, written work, voice, verbal statements, portraits (video or still) shall
only be used for public relations, public information, school or parish promotion,
publicity, and instruction. With respect to publication in parish/school web pages,
St. Jude Catholic Church further agrees that:
Children and young people age 15-17 will not be
identified by personal details other than first and last name. These details
include e-mail or postal addresses, telephone or fax numbers.
Pictures of one to three students are permitted as
long as an appropriate release form has been signed by the parent/guardian of each
individual shown in the picture. Pictures of four or more students are permitted without a
release form. For any picture of students that is published on any parish web site,
only the first names or first name and last initial of the students shown in
those pictures are to be included with the image or in accompanying text. Where text on a
page is not associated with an accompanying image, first and last names of students
may be used. No signed waiver is required prior to publishing in these cases.
St. Jude Catholic Church will immediately
comply with any request by a parent or legal guardian for the removal of specific
photographs featuring their child or references to their child’s name.
No other personal information about a
student or minor is allowed, including email address, phone number, or home address.
Student and Parent/Guardian understand and agree that:
No monetary consideration shall be paid;
Consent and release have been given without coercion or
duress;
This agreement is binding upon heirs and/or future legal
representatives;
The photo, video or student statements may be used in
subsequent years.
If the Student and/or Parent/Guardian wish to rescind this
agreement they may do so at any time with written notice.
Student's Name:________________________________
Effective Date of
Agreement:___________
(Print Name)
Parent/Guardian:_______________________________
(Print Name)
_______________________________
(Signature)
St. Jude Catholic School has no control of
media use of pictures/statements which are taken without permission.
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