2. 
4. Media Authorization and Release Form

   This form must be completed for all individuals participating in a Dallas Park and Recreation programs. If the individual is under the age of 18, the form must be completed by a parent or guardian. By submitting this form, you are agreeing to the terms listed within the form.

6. Participant First Name*
7. Participant Last Name*
9. Participant Phone Number
10. Participant Email Address
11. Is the individual under the age of 18? *

    1. Yes
    2. No
13. Address1
14. City
15. Zip
17. Parent / Guardian Name*
18. Parent / Guardian Email Address*
19. Phone Number
21. Please name the program or activity that you are participating in. *
22. What is the location of the activity? *
24. Permission to utilize images*

    1. Yes, I Agree

    Intending to be legally bound hereby, I myself, and family, give and grant to Dallas Park and Recreation Department, its successors, and any person acting under its permission and authority, the unqualified right, privilege and permission to reproduce in every manner or form, publish and circulate video tapes, audio, film, photographs, and transparencies of me, my child(ren), family, and/or property and recordings of my (their) voice via Radio/TV appearances, arising out of the production of any such forms of likenesses by Dallas Park and Recreation Department and its appropriate entities, and I hereby grant, assign and transfer to Dallas Park and Recreation Department all rights and interest therein at no charge to Dallas Park and Recreation Department.

26. Images registered with Dallas Park Department*

    1. Yes, I agree

    I specifically authorize and empower Dallas Park and Recreation Department to cause any such video tapes, films, photographs and transparencies of me, my child(ren), family and/or my property, and recordings of my (their) voice, to be copyrighted or in any other manner to be legally registered in the name of Dallas Park and Recreation Department.
28. Indemnification *

    1. Yes, I agree

    I, for myself, my family, my child(ren), my heirs, executors, administrators and assigns, hereby remise, release and discharge Dallas Park and Recreation Department for and from any and all claims of any kind whatsoever on account of the use of such property and recording of my (their) voice, including but not limited to any and all claims for damages for libel, slander and invasion of the right of privacy.
30. Compentency*

    1. Yes, I agree

    I am of lawful age and of sound mind, and have read and understand this Authorization and Release.
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field