2006-2007
Valley Community Coalition
505 Larrabee Street - Clermont, IA 52135 * VCC Office - 563-423-5171 * Youth Center - 563-423-7380

Publications, Video, Internet Consent and Release Agreement

The Valley Community Coalition (VCC) strives to maintain a high level of security for your child(ren). 

Students participating in (VCC) and SODA (Students OK Without Drugs or Alcohol) events are occasionally asked to be part of  publicity, publications and/or public relations activities and promoting the VCC/SODA website located at www.vccsoda.org  In order to guarantee student privacy and ensure your agreement for your child to participate, the VCC asks that you sign this form and return it to the VCC office or staff.

The policy of the Valley Community Coalition is to NOT allow the release of residential addresses, phone numbers, and email addresses of students.  On our public Internet site, only first name and last initial will be used. 
The form referenced below indicates approval for the student's name, picture, art, written work, voice, verbal statements or portraits (video or still) to appear in VCC publicity, publications, videos or on the VCC website. For example, pictures and articles about VCC activities may appear in local newspapers or publications. These pictures and articles may or may not personally identify the student. The pictures and/or videos may be used by the VCC in subsequent years.
 
AGREEMENT
Valley Community Coalition agrees that the student's name, picture, art, written work, voice, verbal statements, portraits (video or still) shall only be used for public relations, public information, VCC promotion, publicity, and instruction.

Student and Parent/Guardian understand and agree that:

  • No monetary consideration shall be paid;
  • Consent and release have been given without coercion or duress;
  • This agreement is binding upon heirs and/or future legal representatives;
  • The photo, video or student statements may be used in subsequent years.

I release the Valley Community Coalition, its representatives, staff and all organizations and individuals related to the Valley Community Coalition from any and all liabilities or damages that result from the use of this student's name and/or photographic likeness on the official website (www.vccsoda.org)  of the Valley Community Coalition or release of this student's name and/or photographic likeness to any newspapers or magazines for publicity and/or recognition purposes.

My permission shall remain in effect unless revoked by me and communicated to the Valley Community Coalition in writing. 

If the Student and Parent/Guardian wish to rescind this agreement they may do so at any time with written notice.

_____Yes, I give permission for my child to be photographed for use in promoting VCC activities in publications, video, and/or on the VCC website.

_____No, I DO NOT give permission for my child to be photographed for use in VCC  activities in publications, video and/or on the VCC website.

Effective Date of Agreement:________________________________
Student's Name:________________________________
(Student's signature)		 ________________________________
 (Print Student Name)
Parent/Guardian:________________________________
(Parent Signature)		 ________________________________
(Print Parent Name)

Valley Community Coalition  has no control of media use of pictures/statements which are taken without permission