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2. Release Form for Images and Recordings

   City of Belleville

4. Please initial in the spaces below and sign your full legal name at the end of the release form to approve the use of any images and recordings that you participated in.

6. Any images or audio and video recordings collected may be used for:*

   1. Images / Audio recordings / Video recordings can be used for City of Belleville promotions, social media and marketing initiatives.

8. Any images or audio and video recordings collected may be used for:*

   2. Images / Audio recordings / Video recordings can be used for internal or external presentations.

10. Any images or audio and video recordings collected may be used for:*

    3. Images / Audio recordings / Video recordings can be used for future projects.

12. Any images/audio/video recordings will only be used in the ways you consent to.

    Your name will not be associated with these recordings in any presentations or publishing. Signing this release is voluntary.

    I consent to audio/video recording(s) for the above-described purposes and certify that I am 18 years of age or older.

    If a child is under 18 years of age, consent must be given by a parent or guardian. 

16. Participant's Name

    If participant is under 18, please print name above.

18. Parent / Guardian Name
20. Signature*
21. Date*
    Date
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field