MODEL RELEASE

SOUTHERN MISSOURI DISTRICT GIRLS MINISTRIES

I, _______________________, do hereby give the Southern Missouri District
Girls Ministries Office and its assigns, licensees and legal representatives the
irrevocable right to use my name (or any fictional name), picture, portrait,
photograph or video and electronic images in all forms and media and in all
manners, including composite or distorted representations, for advertising,
trade or any other lawful purposes, and I waive any right to inspect or approve
the finished product, including written copy, that may be created in
connection therewith. I am of full age. I understand that I will not be
compensated for my time. I have read this release and am fully familiar with
its contents.
Witness: ____________________
Print Name:__________________
Address: ____________________
____________________________

Signed: ___________________
Print Name: _______________
Address: __________________
Phone:____________________
Date: _____________________

CONSENT (if applicable)

I am the parent/guardian of the minor named above and have the legal
authority to execute the above release. I approve the foregoing and waive any
rights in the premises.
Witness: ______________________
Print Name: ___________________
Address: ______________________
______________________________

Signed: ___________________
Print Name:________________
Address: __________________
Phone: ____________________
Date: _____________________

Our intent is to use the pictures in our District Publications, videos and
possibly power points to show other young ladies what retreat is all about.
We will not sell these to anyone. Any that would be on the Internet would be
adjusted so as not to identify any single individual. Thank you for your
consideration of this matter.

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