Consent Form Parent's First Name* Parent's Last Name* Parent's Email* Parent's Phone Number* Child's/Children First Name/-s* Child's/Children Last Name/-s* Parent's Instagram Handle/Username Child's/Children Instagram Handle/Username Without the expectation of compensation or other remuneration, now or in the future, I hereby give my consent to MM10 Academy, its affiliates and agents, to use my image and my child's/children images and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me/my child/my children and/or record my voice; (b) Permission to use my name/my child's name/my children names; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me/my child/my children, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness. This consent is given in perpetuity and does not require prior approval by me.Signature*
