Child/Teen: *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Cell Phone *

(###)

###

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Media Release

I hereby give my consent to all photographs, audio recordings, academic work, and/or video recordings taken of me or my minor child St. Columba’s Church or their designee. I understand that any such photographs, audio recordings, academic work, and/or video recordings become the property of St. Columba’s and may be used by the parish, Diocese of Atlanta for educational, instructional, or promotional purposes in broadcast and media formats now existing or created in the future, including print and audiovisual presentations.

Yes

No