Media Release Waiver

I, the undersigned, do hereby grant or deny permission to Mighty Crane Kenpo Karate image of to use the myself or my child,

Name(s)

as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Mighty Crane Kenpo Karate Website.

Single choice

Deny permission to use myself or my child’s image at all.

Grant permission to use myself or my child’s image in the following ways (mark all that apply):

Limited usage: I want myself or my child’s image used within

the Mighty Crane Kenpo Karate setting only (not in the larger community).

Limited usage: I want myself or my child’s image used for educational (not marketing). This could be either within Mighty Crane Kenpo Karate or in the larger community. One example of this could be videos in parent education classes.

Limited usage: I want myself or my child’s image used on printed materials only materials only (no digital or video use).

Unrestricted usage: I give unrestricted permission for myself or my child’s image to be used in print, video, and digital media. I agree that these images may be used by Mighty Crane Kenpo Karate for a variety of purposes and that these images may be used without further notifying me. I do understand that I or my child’s last name will not be used in conjunction with any video or digital images.

Name of Guardian/Parent

Date picker

I hereby give my consent to the above according

to the Terms & Conditions.

Confirm with your initials