Photo and Name Release Form

I hereby license and consent to the use by Platinum Gymnastics Academy (PGA), of any and all gymnastics related photographs that have been taken of my child or children: ________________________________ _____________________________________________________________without compensation to me. These gymnastics related photographs may be used for the PGA internet website, PGA print publications, PGA flyers and PGA advertising material. PGA is licensed to use these photographs in any of its print or electronic publications related to gymnastics.

I also license and grant PGA permission to use my child’s first name ONLY on the PGA internet website, PGA calendars, and PGA newsletters.

I hereby acknowledge that I have read and understood the terms of this release and license agreement:

Parent’s Signature: _________________________________

Printed name: _____________________________________

Date: ____________________________________________

Witnessed by: _____________________________________