Parent/ Guardian Consent
PLEASE READ THE FOLLOWING CAREFULLY AND COMPLETE THE REQUIRED INFORMATION:
I hereby consent to any and all health services necessary by Just4Keepers staff to refer my child for consultation to any licensed medical specialist or to any area Emergency Room. I give authority and power to any such physician/surgeon to render any and all health services that may be deemed necessary or advisable. I authorize the Just4Keepers Director to accompany my child and sign permit forms required by the Medical Counter. I understand in case of serious accident or illness every effort will be made to contact me. I understand I will be responsible for any costs or care provided.
Photo/Video Release Form
By signing this release form, I authorize J4K of Central Virginia to use the following personal information:
(1) My/ my child's picture – including photographic, motion picture, and electronic (video) images.
(2) My/ my child's voice – including sound and video recordings.
I hereby grant to J4K of Central Virginia, its subsidiaries, licensees, successors and assigns, the right to use, publish, and reproduce, for all purposes, my/ my child's name, pictures of me/ my child in film or electronic (video) form, sound and video recordings of my/ my child's voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media including, without limitation, cable and broadcast television and the Internet, and for exhibition, distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences and in brochures and other print media. This permission extends to all languages, media, formats and markets now known or hereafter devised. This permission shall continue forever unless I revoke the permission in writing.
I further grant J4K of Central Virginia all right, title, and interest that I/ my child may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grant J4K of Central Virginia the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for marketing, communications, or advertising purposes, as it deems fit.
I hereby waive the right to receive any payment for signing this release and waive the right to receive any payment for J4K of Central Virginia's use of any of the material described above for any of the purposes authorized by this release. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer generated scanned image and other electronic media that may be used in conjunction therewith or to approve the eventual use that it might be applied.
I acknowledge that I have read the foregoing and I fully understand the contents.