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Parent/Guardian Name
Name of Minor Individual Being Photographed
I, the parent/guardian of the minor child listed on this application, grant Boys & Girls Clubs
of Silicon Valley (BGCSV) my permission to all rights and consent to copyright, use, or
re-use, publish, or re-publish, copy, exhibit or distribute all photographs, videotapes,
motion picture films and/or audio tapes involving the use of my child’s voice or image, by
BGCSV for internal use, educational use, advertising or promotion without restriction as
to frequency or duration of usage and without compensation to me.
Boys & Girls Clubs of Silicon Valley may use my child’s first name and such photographs,
recordings and/or images for any and all purposes including art, advertising, promotional,
educational, and web, and in all media, including electronic, digital, broadcast, and print
media, without further compensation to me.
This release is valid for one year and may be revoked at any time by contacting Boys &
Girls Clubs of Silicon Valley in writing.
Clear Signature

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