Media Release Form PhoneThis field is for validation purposes and should be left unchanged.Participant Name First Last Date MM slash DD slash YYYY Permission to Use Name and Likeness(Required) I hereby irrevocably grant and assign to Dakota Stage the right to use my “Likeness,” in any media in connection with or for the promotion of this Program and/or Dakota Stage. This permission includes, but is not limited to, the right to copyright, use, and publish my name and likeness in print publications, public broadcasts, CD-ROM format, and any other medium, for any lawful purpose, including trade, exhibition, illustration, promotion, publicity, advertising, and electronic publication. I understand and agree that: No other party has been granted an exclusive license with respect to my name and likeness. No other party’s authorization or consent is required with respect to the permission granted to the Released Party under this Consent and Release. I waive any right to inspect or approve the Released Party’s use of my name and likeness, or the advertising copy or printed matter that may be used in connection with the use and/or publication of my name and likeness. I release the Released Party (and all persons acting under its permission or authority) from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, or any other claim related to the use of my name and likeness. I warrant that I have read this Consent and Release prior to signing it, that I understand it, and that I freely enter into this Consent and Release. Participant Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Participant Age The participant is under 18 years of age. Parent/Legal Guardian InformationIf the participant is under the age of 18, parent/ legal guardian please complete the below information.Parent/Legal Guardian Name First Last I am the parent/ legal guardian of the above-named minor and I endorse the above statement in his/her behalf.Parent/Legal Guardian Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
