Cornerstone Mentoring Program

PHOTO & MEDIA RELEASE FORM

(Parent/Guardian Consent)

Child Information

Child’s Full Name: _________________________________________

Child’s Age: ___________

Parent/Guardian Information

Parent/Guardian Full Name: _____________________________________________

Email Address: ________________________________________

Phone Number: ______________________

Consent Agreement

I authorize Cornerstone Youth Mentoring Program to capture, store, and use photographs, videos, or audio recordings of my child for:

• Website content
• Social media posts
• Promotional materials
• Program documentation
• Digital or printed publications

I understand that:

• My child’s image may appear publicly online.
• No compensation will be provided.
• I may revoke consent at any time in writing, but revocation will not affect materials already published.

Permission Level (Select One)

☐ Full Permission — My child’s image may be used publicly, including on the website and social media.

☐ Limited Permission — My child may appear only in group photos and will not be individually identified.

☐ No Permission — Do not use my child’s image in any public materials.

Digital Signature _________________________________________

Parent/Guardian Signature (Typed): _______________________________________________

Date: _________________

Additional Notes (Optional): _______________________________________________________

_______________________________________________________________________________