Saint Ephrem School

5340 Hulmeville Road

Bensalem, PA 19020

Photo Release Form

School Year  ___________________                                    Room #  ________________                        

I, _________________________________________________________________, hereby give the Archdiocese of Philadelphia, its successors and assigns and those acting with its authority, the unqualified right and  permission to reproduce, copyright, publish, circulate or otherwise use any school pictures of my child produced by the Archdiocese of Philadelphia.  This authorization and release covers the use of said school pictures in any published form and any media of advertising publicity.

I also understand that our school may be identified by name and I fully understand that this is a complete release of all claims against the Archdiocese of Philadelphia or any other person, firm or corporation by reason of any  such use of such school pictures.

I hereby warrant that I am free to give this permission.  I further warrant that the information I have provided is, to the best of my knowledge, true and accurate.

__________________________________________                        ___________________

Signature of Parent(s)/Guardian(s)                                                         Date

_______________          ____________

Grade                               Room#

__________________________________________                        ___________________

Student Name                                                                                      DOB

Address:          ___________________________________________

                        ___________________________________________

Phone #            ___________________________________________