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)

Parent's Signature________________________

Date Signed _____________________________

urbanlifetraining.org

202-544-5081

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