Participant Name *

First Name

Last Name

Permission

I give permission to the Synergy At Play Productions to photograph and record my image and voice, or that of my child/ward, on still photographs, motion picture film, audio tape, video tape or digital media and to use this material, and/or similar material provided to Synergy At Play Productions by myself or by third parties involved in events, in whole or in part, now and in the future, through the media of television, film, Internet, multimedia presentation, radio, audiotape, videotape, in printed form and display form, as well as any other future forms that may become relevant. I assign and transfer to Synergy At Play Productions any and all proprietary rights, including copyright, and waive all personal rights which I or my child/ward may have in this material. Synergy At Play Productions is only responsible for official uses of above mentioned media. Any personal uses outside of the promotional uses outlined above are not monitored by, nor the responsibility of, Synergy At Play Productions.

Yes, I give my permission as set out above

No, I do not give my permission as set out above

Parent/Guardian Name *

First Name

Last Name