Authorization and release form

Cache Valley School of Ballet

Authorization and Release to use and disclose information for media or communication.

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Authorization *
A. This authorization and release allows the Cache Valley School of Ballet to release the following information about you to the public: your name, your image (photograph, video, films, etc.), your story, and statements. B. If you don’t want the CVSB to disclose certain information, please put a check next to the information that you DON’T want disclosed.
Fill in if marked "Other (if applicable)" above
Understanding *
I understand the following (please read and mark each one).
Signature of Subject *
Signature of Subject
By signing below, I release my information to, and authorize, the Cache Valley School of Ballet to disclose that information in publications, for example in electronic, audio, printed form in news media, in publications, advertising brochures, fundraising pamphlets, social media, website, and other communications. My questions about this Authorization and Release have been answered to my satisfaction.
If under 18, signature of parent or guardian:
If under 18, signature of parent or guardian: