Media Release

Student Full Name

First NameLast Name

Student Email Address*

example@example.com

Program Location*

I hereby GRANT or DO NOT GRANT permission to College Steps (CS) to use my picture, video or voice recording for purposes of promoting College Steps.

I GRANT PERMISSIONI DO NOT GRANT PERMISSION

I GRANT permission to College Steps (CS) to use my picture, video or voice recording for purposes of promoting College Steps.

Student First NameStudent Last Name

By signing this form I recognize that I am not required to (1) have my picture taken or be recorded in a College Steps produced video and (2) my refusal to sign the current consent form will in no way exclude me from College Steps programming. Click the boxes below:

I hereby voluntarily and without compensation authorize picture and/or video recordings to be made of me or of the above-named individual if the individual is legally unable to give consent) by College StepsI authorize the disclosure of the picture and/or video recording to College StepsI recognize that my picture and/or video recording is intended for promotional purposes of College Steps only

I have read and understand the foregoing and I consent to the use of my picture an/or video/voice as specified for the above-described purpose. I further understand that no royalty, fee or other compen- sation of any character shall become payable to me by College Steps for such use. I understand that consent to use my picture, video and/or voice recording is voluntary and my refusal to grant consent will have no effect on any CS programming to which I may be entitled. I further understand that I may at any time exercise the right to cease being filmed, photographed or recorded, and my rescind my consent for up to a reasonable time before the picture, video or voice recording is used.

Signature of Individual

I currently have a Legal Guardian*

YesNo

Signature of Legal Guardian*

Date

I DO NOT GRANT permission to College Steps (CS) to use my picture, video or voice recording for purposes of promoting College Steps.

Student First NameStudent Last Name

Date

College Steps Media Release