Reach 1600

Student Media Consent and Release

Without expectation of compensation or other remuneration, now or in the future, and in consideration of Reach 1600 Foundation (the “Reach 1600”) giving me permission to take part in activities hosted or sponsored by Reach 1600, I hereby give my consent to Reach 1600 Foundation, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness. This consent will remain in effect until revoked upon my written notice to Reach 1600. The undersigned affirms that he or she is a parent or legal guardian of the minor named below, and hereby consents to this Student Media Consent and Release on behalf of such minor.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. *