Youth Members Name *

First Name

Last Name

Youth Mobile Number (if applicable)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Mobile *

(###)

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Media Consent

Photographic / Media Consent Form This consent form will authorise OurChurch and Love This City to use and publish photographs and any other form of media material for informational and promotional purposes.These photos/video will not be available to any other person or company other than OurChurch and LOVE THIS CITY. Images and media may be used, but will not be limited to print, newsletters, blogs, advertising, social media and promotional material, website and audiovisual presentations. I hereby assign to OurChurch and LOVE THIS CITY the right to any photos, video, and/or sound recordings taken. I authorize the reproduction, without limitation or compensation, in any form of delivery, including websites and webcasts, be it within the church and community. This media consent will be kept by OurChurch and Love This City as reference for individual approval. I will notify OurChurch and LOVE THIS CITY if there are any changes to my decision. After reading the explanation above, I authorise OurChurch and Love This City to take and use any photographs or media for publications, productions and presentations, including electronic / internet marketing material.

I Agree to this above Photographic/Media Consent

Form Completed by (must be over 18 years of age) *

I agree that this digital signature confirms that the above information is correct for my child at time of submission.

First Name

Last Name