Helping Kids & Teens Understand & Fulfill the Power of a Dream!

Minor Release Form I, (Please Print name) ____________________________________________________ of

_________________________________ ___________________________________(address) warrant that I am the parent or legal guardian of

(Please insert name) ___________________________________________________________________

who is under the age of 18 Years (the Minor). I hereby give to Lead4life Inc, its legal representatives, successors, and assigns and all persons or corporations acting with its permission, the permission with respect to the photographs, pictures, films, tapes and other pictorial recordings taken or to be taken of the Minor in any medium (including electronically)

on _______________________________________________(insert date)

at _________________________________________________________________(insert location) to use, reproduce, copy, publish, communicate electronically and broadcast the same, in whole, in part or in composite, whether altered or enhanced or in conjunction with any other images or text, in still, single, multiple or moving form and using any medium, including but not limited to, print, film, video, CD and the Internet, for any lawful purpose.

I acknowledge that Lead4life Inc. owns the copyright and related rights in the above works and that I have no right to inspect or approve the finished product that may be used. I further release Lead4life Inc., its officers, employees and agents and all persons or corporations acting with its permission, from any claims or liability arising from or associated with any form of loss or damage, foreseen or unforeseen, associated with the lawful use of these images unless it can be shown that said reproduction was maliciously caused, produced and published for the sole purpose of subjecting the Minor to conspicuous ridicule, scandal, reproach, scorn and indignity.

Signed by the above named parent/guardian

______________________________________________________ (Signature) (Date)________________

___________________________ __________________________________________ (Home telephone number) (Email Address)

Lead4life Inc. | 809 Sedgegrass Drive, Champaign, IL 61822 | www.lead4life.org | 217.293.2123 | This is a legally binding release to Lead4life Inc.