- Media Release Form-

Session 9


Student Name *
Student Name
Parent/ Gaurdian Name (if under 18)
Parent/ Gaurdian Name (if under 18)
Media Release
I, the undersigned, do hereby grant or deny permission to Breathe Bravely to use the image and/or recording of the above named student, for promotional, informative, and educational purposes for the sINgSPIRE program. *
Grant Permission in the following ways: *
Please check all that apply. See below for details.
Educational Usage: Images and/or recordings used in the setting of Breathe Bravely and educational materials. One example of this is the use of images and/or recordings participating in sINgSPIRE program - showing its impact on CF for educational purposes during CF Family Days, conferences, or public education. Social Media Usage: Video compilations, images, and/or recordings of sINgSPIRE students used to share the mission, impact, and vision of sINgSPIRE via the Breathe Bravely Facebook page and Instagram account. Promotional Materials: Images and/or recordings used for promotional purposes such as printed materials, brochures, newsletters, and digital image design as used on the Breathe Bravely website. An example of use would be informative informational brochures for CF Care Centers to share with interested patients. (The last name or location of the student are never used in any sharing of images and/or video.)
Today's Date *
Today's Date
By typing your name in the box below, you acknowledge that you have read and filled out the above release to the best of your known ability.