Mail this form to Starry Night Productions

P.O. Box 1648 Woodbridge, CA 95258

Parental or Legal Guardian

Permission Form

For Participation & Photography of a Minor

I give permission for __________________________________________________________, birth date: __________________, to participate in the “Teen Poets of San Joaquin & Sacramento Counties Showcase” on 10-24-10 at the Lodi Public Library in Lodi, CA. This event is hosted by Starry Night Productions P.O. Box 1648 Woodbridge, CA 95258

I also give permission for photographs of this minor to be taken during this event.

Starry Night Productions cannot sell these photographs. Starry Night Productions and the Lodi Public Library can display these photographs on various websites, can include these photographs in media press releases, can include these photographs in printed materials, and can include these photographs in flyers.

The first and last name of this minor CAN be used for print or online materials and CAN be released to the media without additional permission granted from me.

Parent, legal guardian, or assigned social worker:

Print name, address, phone number, and e-mail address if e-mail address is available:

Name:

____________________________________________________________________________

Relationship to Minor:

____________________________________________________________________________

Address:

____________________________________________________________________________

____________________________________________________________________________

Phone:

____________________________________________________________________________

E-Mail:

____________________________________________________________________________

Signature: ___________________________________________________________________