Media Release Form – Smart Talented Leaders (STL) Scholars Program

This is a legally binding Release made by me to the Smart Talented Leaders (STL) Scholars Program, Inc. *

Please type your name as your signature.

LET IT BE KNOWN, that the undersigned herein states that his/her name, voice and/or image is reflected in the photograph(s), audio and/or audiovisual recordings to be used in publicity and/or news releases and/or production of education materials, and that in consideration for the STL SCHOLARS PROGRAM publishing my name, voice, and/or image, the undersigned hereby authorizes STL SCHOLARS PROGRAM and those acting pursuant to its authority to use my name, voice and/or image without restrictions or limitations as deemed appropriate by STL SCHOLARS PROGRAM and does hereby and for his/her heirs, executors, administrators, successors and assigns expressly release, acquit and forever discharge STL SCHOLARS PROGRAM, its agents, servants, officers, directors and employees of and from any and all claims, actions, causes of action, demands, rights, damage, costs, loss of service, expense and compensation whatsoever which the undersigned participant may have or which may hereafter accrue on account of or in any way growing out of use of my name, voice, and/or image in photographs, audio and/or audiovisual recordings. *

Please type your name as your signature.

The undersigned further agrees to indemnify and hold harmless STL SCHOLARS PROGRAM, its governing board, committee and its agents, servants, officers, directors, and employees from each and every claim, demand, loss, damage, or expense for any and all liability or damages resulting from the use of said photograph(s), audio and/or audiovisual recordings that may in any way relate to his/her representation that he/she is the person whose name, voice, and/or image is reflected therein. *

Please type your name as your signature.

The undersigned understands that this Release covers liability, claims and actions caused entirely or in part by acts or failure to act of the STL SCHOLARS PROGRAM, or its governing board, committee, employees, or agents, including but not limited to negligence, mistake, or failure to supervise by the STL SCHOLARS PROGRAM. *

Please type your name as your signature.

The undersigned further declares that no promise, inducement or agreement not herein expressed has been made to the undersigned, and that the undersigned fully understands this agreement, and that this Release contains the entire agreement between the parties hereto, and that the terms of this Release are contractual and not a mere recital. *

Please type your name as your signature.

Participant’s Name: *

First

Last

(Your typed name will serve as your signature)

Parent/Guardian’s Name:

First

Last

Parent or Guardian must sign for a minor under age 18 at date of event. (Your typed name will serve as your signature)

Address: *

City, State & Zip Code: *

Email: *

Phone Number: *

Please include your area code.

Scholarship Recipient or Guest of Recipient: *

Name of Event Attending: *

Date of Event: *

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