Permission for
Publication of Personal Information
Web and Print
The above organization has my permission to use my child’s image and/or name for publicity and communication purposes on their web site and/or in printed media. I also give permission to use the following specific personal information for intercommunication purposes on a secure portion of the site.
(Please
ONLY give information you want to include in the web database.)
Player Name:______________________________________________
Parents’ Names:____________________________________________
e-mail:____________________________________________________
Address:___________________________________________________
Phone:____________________________________________________
Cell Phone:_________________________________________________
Giving this permission releases the above organizations, their directors and officers, and all persons performing work on their behalf from all liability associated with the stated use of this material. I further understand that every effort will be made to maintain the security and privacy of this information for distribution only within the soccer team and the soccer playing community. However, this security and privacy is not guaranteed. I must immediately notify the League President, president@stcloudsoccer.com if I am aware of any breach of security.
_______________________ ______________________________________
Date Parent/Guardian Signature
_______________________ _______________________________________
Date Witness Signature
____________________________ ________________________________________________
Date Witness
Signature