Summer Registration

Guardian #1*

First Last

Guardian #2*

First Last

Child's Name:*

First Last

Age:*

Email Address*

Birth Date:*

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone:*

Parent Release for Media Recording

I, the undersigned, do hereby grant or deny permission to Bits & Bytes Academy to use the image of my child, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Bits & Bytes Academy Web site.*

Deny permission to use my child’s image at all.
Grant permission to use my child’s image in the following ways (mark all that apply):

Limited usage: I want my child’s image used within the Bits & Bytes Academy setting only (not in the larger community).
Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within Bits & Bytes Academy or in the larger community. One example of this could be videos in parent education classes.
Limited usage: I want my child’s image used on printed materials only (no digital or video use).
Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by Bits & Bytes Academy for a variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images.

I agree that the information provided herein is true and correct to the best of my knowledge.

Parent/Guardian Signature:*

Known medical conditions i.e. diabetic, asthmatic, drug allergies:*

Parent/Guardian Signature:*

Date:*

Summer Registration

Summer Registration

Parent Release for Media Recording

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