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MOUNT CARMEL ACADEMY
7155 Ashburn, Houston, TX 77061 * An Houston ISD Contract-Charter High School
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M E D I A R E L E A S E F O R M
I hereby grant permission to Mount Carmel Academy, Houston I.S.D. and their representatives or contractors to photograph and/or interview my child,
__________________________________________. It is my understanding that this photograph/interview or portions thereof will be used for public view (but not limited to) print media, television, internet and other media.
I agree to participate in this project without financial remuneration, and I understand that this releases the photographer/interviewer from any future claims as well as from any liability arising from the use of said photograph/interview.
This release form shall serve to release my child for the duration of the current school
year during which the release is signed and dated. Should I change my mind, I will
notify Mount Carmel Academy in writing either by letter or fax.
Name of child ________________________________________________________
Address _____________________________________________________________
City, State, Zip________________________________________________________
Signature of parent or guardian __________________________________________
Date________________________________
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