VIDEO/IMAGE RELEASE FORM

The Hippodrome State Theatre may use photos or video tape of my child for archival, marketing, and/or civic programs.

I, the undersigned, hereby give my consent to the Hippodrome State Theatre to photograph or video tape productions of the classes and presentations.  I am aware that parents of the participants photograph and video tape performances as well.

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Print Actor Name

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Actor Signature     Date

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Print Parent Name

______________________________________ _____________
Parent Signature     Date

WE MUST HAVE THIS FORM ON FILE
IN ORDER FOR YOUR CHILD(REN) TO PARTICIPATE IN THE PRESENTATIONS.