Minor Photo/Video Usage Parental Consent Form

Child’s Information

Full Name Date of Birth

Parent/Guardian Information

Full Name Relationship to Child Contact Number Email Address

Consent

I, the undersigned, hereby give permission for the above-mentioned child to be photographed and/or recorded on video. I allow the use of such photograph(s) or video(s) for:

If there are any restrictions, please specify below:

Parent/Guardian Signature Date