MEDIA RELEASE FORM

If you have any questions contact Ms. Oliver at (204) xxx- xxxx ext. xxx or

oliverm@myumanitoba.ca

The English Additional Language Club promotes students learning English by getting actively

involved with the school and community, and as such, they will be taking photos of themselves

and their experiences making lasting connections with others and exploring their new

community.

• I, (student name) ________________________________________________, hereby release

my image, likeness, and the sound of my voice, as it is recorded. I agree that the footage/photos

may be edited and used, in whole or in part, in all media, including, but not limited to, books,

audio and video, the Internet, television, radio and cable broadcast.

• I consent to the use of my name, likeness, voice, and biographical information in connection

with the distribution and promotion of the media.

• I hereby waive all rights to inspect and approve the finished product or its use.

Student Name (Print): ___________________________________________________________

Student Signature: ______________________________________________________________

Parent or Guardian Signature: _____________________________________________________

Date: _________________________