The person named is of legal age to consent or the legal parent/guardian of a minor or person unable to consent on his/her own behalf. By accepting, with full knowledge of the facts and circumstances surrounding the program, I acknowledge my child’s participation in the program and by consent grant Start With Me, Inc. permission to:

1. Use written/oral history, pictures, videos, voice recordings or any other likeness of the individual so long as use is for the exhibition, advertising, marketing or program aspects of Start With Me, Inc.

2. Use any Name, Mark or Logo whether or not registered, in any manner consistent with the balance of this release and consent

3. Use individual’s name in pictures, videos, voice recordings, presentations or any other likeness for all media including print, video and online formats to be used with the general public

4. Use any Name, Mark, Logo, whether or not registered, in any manner consistent with the balance of this release and consent

No picture, statement, audio recording or other likeness of individual will be used for any other purpose or at any other time without consent. I understand that I may revoke this release and consent by sending a written request to Start With Me, Inc. via e-mail at xavier@startwithme.org. I understand that I must submit a request to revoke this consent and release 30 days before any publication, video or other media goes to production, and that after publications, video or other media go to production I will not be able to revoke this consent and release. If I am part of a photo, video, or audio production, I understand that once the images and/or audio are taken I cannot revoke this consent and release. This release will expire five years from date of signature. I understand that I will not receive payment of any kind for use of my pictures, words, etc.