MEDIA RELEASE FORM
give ULTRA Teen Choice permission to use any video tapes, photographs and/or quotes as requested of my minor son/daughter.
These may be used in videos, classroom session presentations and at conference exhibits. Photos may be used in brochures, fliers, web page and various other media for publicity and/or for the promotion of the ULTRA Teen Choice program (Please mark through and initial any areas you DO NOT want us to use photos or videos.)
I give permission for the minor's first name to be used. Yes_____ No _____
(If no is checked, only grade of minor will be used.)
Minor's Name ___________________________ (please print)
Date Signed _____________________________