Dempsey Center›Registration Forms›Space to Breathe Media Release 2024

Space to Breathe 2025 Media Release

PARENTAL WAIVER AND RELEASE OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT FOR MINOR PARTICIPANT

This form contains 2 sections:
  • The first section addresses release information about my involvement program with other S2B participants.
  • The second section addresses release of information about my involvement with the public.
You may choose to agree to one release, both releases, or no release of information.

Section 1: Authorization to release information with other S2B participants

PLEASE READ CAREFULLY, THIS IS A LEGAL DOCUMENT
By signing below, I give my permission for the Dempsey Center (DC), its employees and agents to release information about my involvement in the Dempsey Center’s Space to Breathe (S2B) 2025 program with other S2B participants, specifically photos and videos captured of me during my participation in this year’s S2B program.

By completing this form, I understand and acknowledge that this constitutes permission for the DC to release photos and/or videos of me from 2025’s S2B Program to other participating S2B families and teens. I understand I can revoke this permission at any time, except for any content that has already been shared by DC before the time of my request for revocation. I understand that, once photo and video content that includes me is released/disclosed to a third party (i.e., other S2B participants and families), the content may no longer be protected by federal privacy regulations and may be redisclosed by the person that receives the content. My revocation of permission must be given in writing to the DC Communications Department, signed and dated by me.

I may refuse to sign this authorization form. Partial or incomplete information will be labeled as such. I understand that, if I refuse to sign this authorization form, or if I revoke it, it may result in DC being unable to disclose any information.

MINOR PARTICIPANT/PARENT/GUARDIAN AUTHORIZATION AND ACCEPTANCE OF ALL TERMS

Minor Participant Full Name:(Required)
MM slash DD slash YYYY
Name of Parent Guardian:(Required)
I understand that my typed name below will carry the same effect as my written signature.(Required)
Signature of Parent Guardian:
I understand that my typed name will carry the same effect as my written signature.
MM slash DD slash YYYY
Participant (or Parent/Legal Guardian) Home Address:(Required)

Section 2: Authorization for the Release of Information to the Public

I give my permission for the Dempsey Center (DC), its employees and agents to release information about my involvement with the DC in the following manner: Check all that you agree to:
By completing this form, I understand and acknowledge this constitutes permission for the DC to release my testimonial and/or picture for promotional purposes and to be used in one of the following ways: to promote a workshop in the local newspaper or to create an annual report or other brochure for the DC. Any additional instructions or limitations on the release of my testimonial may be written on the back of this form. I understand I can revoke this permission at any time, except for information already disclosed by the DC. I understand that, if this information is disclosed to a third party, the information may no longer be protected by federal privacy regulations and may be redisclosed by the person or organization that receives the information. My revocation of permission must be given in writing to the DC Communications Department, signed and dated by me. I may refuse to sign this authorization form. Partial or incomplete information will be labeled as such. I understand that, if I refuse to sign this authorization form, or if I revoke it, it may result in the DC being unable to disclose any information.
I would like a copy of this form:(Required)
Name of Minor Participant:(Required)
Name of Parent Guardian:(Required)
I understand that my typed name below will carry the same effect as my written signature.
Signature of Parent Guardian:
I understand that my typed name will carry the same effect as my written signature.
MM slash DD slash YYYY