KIDS: Kids' Web Pages Release Form

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Kids' Web Pages Parents Release Form

 

Release - Please print and complete

I, the undersigned, authorize the State of Connecticut to use any original material submitted by my child through the ConneCT Kids Kid's Web Pages section on the State of Connecticut Website, ConneCT Kids, www.kids.ct.gov,  now and in the future without further notice or compensation, and agree that such material will be freely available for download and distribution. In addition, I agree that my, and/or, my child's name and/or likeness in any form including, but not limited to, still, video, or film photography or audio recording if submitted may be used for the purpose of promoting the State of Connecticut Website and/or the ConneCT Kids Pages.

Child's Name ___________________________________

Child's name as you would like it to appear on the website

__________________________________________________

Permission to use Child's Last Name  Yes ___     No ___

Permission to use Child's School/Grade/Teacher Information   Yes ___   No ___

Permission to use Child's Photo if provided  Yes ___   No ___

Material to be posted ______________________________________

________________________________________________________

________________________________________________________

Parent or Guardian's Signature_________________________________________

Print Name _________________________________________________________

Address__________________________________________________

            __________________________________________________

            __________________________________________________

Date ______________________________

Please send the SIGNED form to the following address unless instructed otherwise: Richard J. Hemenway, Commission on Official Legal Publications, 111 Phoenix Avenue, Enfield, CT 06082





Content Last Modified on 4/19/2007 10:05:40 AM