Rice University

Media Release Form

I hereby grant permission to Rice University to photograph/interview my child, ____________________________________________.

I understand that, if displayed, my child's image will in no way be connected to his/her name. I also understand that this photograph/interview or portions thereof may be used for public viewing in print and/or on the program website. I understand that this agreement releases the photographer as well as Rice University from any future claims, as well as any liability arising from the use of these materials.

Full Name of Student _______________________________________________

Address _______________________________________________

City, State, Zip _______________________________________________

_______________________________________

Parent/Guardian's Printed Name

_______________________________________ ______/________/________

Signature of Parent/Guardian Day / Month / Year

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