Media Release Form

Name Name First Last
Subject is a minor
Legal Guardian Name Legal Guardian Name First Last
Date Date / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Consent to use photo/video

Consent to use photo/video I hereby consent for value received and without further consideration or compensation to the use (full or in part) of all video and/or photos taken of me and/or recordings made of my voice and/or written extraction, in whole or in part, of such recordings or musical performance for the purposes of illustration, broadcast or distribution in any manner including but not limited to digitally and in print, including but not limited to YouTube, Vimeo, Facebook, Google+ etc. and display on the Waynesburg University website.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Office of University Relations
Phone: 724-852-3293