Rotary Youth Leadership Program
Photo and Video Release Form
For valuable consideration received, I hereby give the Center for Creative Leadership® (the Center)
absolute and irrevocable right and permission, with respect to the photographs and videotape that have
been taken of me or in which I may be included with others:
(a) To copyright the same in the name of the Center.
(b) In conjunction with other photographs, in any medium and for any purpose. To use, re-use, publish,
and republish the same in whole or in part, individually or whatsoever, including (but not by way of
limitation) illustration, promotion, and advertising and trade, and
I hereby release and discharge the Center from any and all claims and demands arising out of or in
connection with the use of the photographs and videotape, including any and all claims for libel.
This authorization and release shall also ensure to the benefit of the legal representatives, licensees,
and assigns of the Center as well as, the person(s) for whom the Center took the photographs and
videotape.
I have read the foregoing and fully understand the contents thereof:
Signature of Delegate
_________________________
Printed Name
_______________________________
Date
________________
If Signatory is under 18:
I represent and warrant that I am the parent or guardian of the minor whose name appears above, that I
have read and approve of the foregoing Release, and consent to its execution by my child/ward. I
hereby release the Released Parties as set forth and in accordance with the foregoing Release from
any claims and/or causes of action I may have against them of any nature whatsoever. I hereby fully
and unconditionally guarantee my child's/ward’s releases and waivers as set forth above.
Signature of Parent or Guardian
_________________________
Printed Name
_______________________________
Date
________________