Media Release Form

Please save a copy of this release for your records.

I attest that I am the parent or legal guardian of the listed minor child/children or a representative for an individual who is an adult but lacks capacity to consent and that I have the authority to authorize Easterseals Northern California (ESNorCal), its affiliates, subsidiaries and partners to take photographs, video tape and audio record them and myself for the Easterseals Northern California Family Night Out with the Warriors event.

On behalf of myself and my child(ren), I hereby grant to ESNorCal and its successors, assignees, and licensees a non-exclusive, irrevocable, royalty-free license to incorporate, use (including in major media campaigns), and reproduce the likeness, image, first name, voice, narratives, creative renderings, depictions, pictures, film, photographs, audiovisual recordings, sound recordings or testimonials of me and my child or myself made by ESNorCal or its respective employees and agents, including any biographical
information that appears in the Material (collectively the “Material”) in connection with communications, marketing and fundraising activity of ESNorCal or other Easterseals organizations, in any manner and in all media, including electronic media, whether now known or hereinafter devised, in all territories throughout the world, in perpetuity.

I understand that the Materials may be broadcast or published. Any disclosure of my or my child(ren)’s name(s) will be limited to my or my child(ren)’s first name(s). I agree that ESNorCal shall be entitled to edit, cut, alter, modify, rearrange, add material to, remove material from, or make such other changes to the Material as deemed appropriate, in its sole discretion. I hereby waive in favor of ESNorCal and its successors, assignees, and licensees all moral rights of whatsoever nature in and to the Material.

I acknowledge that the rights described above are granted to ESNorCal on an unlimited basis without any compensation or payment being made for any current or future use. I understand that this authorization is voluntary and that if my child is a client, ESNorCal will not condition any treatment or funding to my child on the completion of this authorization. I hereby release ESNorCal and its successors, assignees, and licensees from any and all claims and demands arising out of or in connection with use of the Materials including, without limitation, any and all claims for invasion of privacy, infringement of my right of publicity, defamation, misappropriation, false light, and any other personal and/or property right(s). I understand that ESNorCal is proceeding in reliance upon this permission.

I have read this release and authorization before requesting my tickets, and I fully understand its contents.




March 2024 v1.0

Connect with Us