Image Release Form

I hereby consent and authorize Cortez Adventist Christian School or its assigns, to use my name and/or the names of my family members who are minors, as listed below, as well as my likeness, photos, videos and other information (or that of family members who are minors) for the purpose of news releases, advertising, publicity, publications or distribution in any manner whatsoever. I further consent to such use I their present form and to any changes, alteration, or additions thereto. I hereby release Cortez Adventist Christian School and Rocky Mountain Conference from all liability in connection with all such uses.

Phone

This field is for validation purposes and should be left unchanged.

Date*

Signed*

First Last

Address*

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

Number*

Minor Family Members to Whom the Release Applies*