Saint Ephrem School

5340 Hulmeville Road

Bensalem, PA 19020

Student Interview  Release Form

 School Year  ___________________

I, _________________________________________________________________, hereby give the Archdiocese of Philadelphia, its successors and assigns and those acting with its authority, the unqualified right and permission to permit my child to participate in a supervised interview with the news media.  This authorization and release covers the use of said interviews in any form and by 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 interviews.

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 #            ___________________________________________