KIDS: Photo Submission Release Form

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Photo Submission Release Form
 
 
 

Release - Please print form and complete

I, the undersigned, authorize the State of Connecticut to use any original material submitted by my child through the ConneCT Kids Photo Submission 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.
 
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 ___

Child's Grade, School and Teacher

______________________________________________________________________________________

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; Phone: 860-741-3027, Ext. 3601; FAX: 860-745-2178.





Content Last Modified on 6/7/2007 3:05:57 PM