Fillable Liability Release Form printable pdf download

LIABILITY RELEASE FORM

(must be completed by student and adult participants)

We (I), the undersigned, hereby release and agree to hold harmless Johnston County

Government and its employees, agents and officers from any and all claims, including those of

our (my) heirs or assigns with may arise from any action or failure to act by any employee,

officer, or agent of the Johnston County in connection with the participation of our (my) child

(Name)__________________________at the NC Teen Driving Summit.

We (I), the undersigned, have read the foregoing and sign it of our (my) own free will.

This the ________day of _________________, 2013

___________________________________________________________________

Parent or Legal Guardian’s Signature

___________________________________________

________________

Address

Phone #

___________________________________________________________________

Adult Participant’s Signature

PHOTOGRAPHIC, VIDEO AND AUDIO CONSENT AND RELEASE FORM

(must be completed by student and adult participants)

I understand that photographs, video and audio may be taken of me during the

summit. I hereby grant Johnston County the right to use any verbal or written statement,

film and/or photograph(s) resulting from the summit in any publicity materials, websites,

books, television, newspapers and magazine articles at the sole discretion of Johnston

County as it relates to promoting awareness campaigns for the cause of reducing teen

fatalities resulting from vehicle crashes. I further consent that my name and identity,

school and city or county of residence may be revealed by descriptive text or

commentary. Neither individual addresses nor telephone numbers will be published

within these materials.

I do hereby grant Johnston County the right to exhibit any such works publicly or

privately, including posting on the agency website. I waive any right, claims or interest I

may have to control the use of my identity or likeness in the photographs, video or audio

and agree that any uses described herein may be made without compensation or

additional consideration to me. I represent that I have read and understand the foregoing

statement and I am competent to execute this agreement.

Name (print)________________________________________________________

Adult Participant’s Signature___________________________ Date_____________

If participant is under the age of 18, consent of the parent or legal guardian

must be given.

Parent/Guardian name (print) _________________________________________

Signature__________________________________________ Date____________

Liability Release Form