Parent Consent for Local News Interview Release

I, the undersigned parent/legal guardian of the minor named below, hereby give my consent for my child to participate in an interview with a representative of the local news media. I understand that this may involve my child being photographed, recorded, or quoted, and I authorize the use and publishing of my child's likeness, statements, and/or voice as part of the news coverage in any format, including print, broadcast, and online media.

Name of Minor: Age of Minor: Date of Interview (if known):

Parent/Guardian Name: Relationship to Minor: Contact Information:

I certify that I am the parent or legal guardian of the above-named minor and have the authority to sign this release. I have read and understand the terms of this consent.