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STEMscopes, Accelerate Learning, Inc.
Media and Print Release Form (Parent/Child)
I, the undersigned, represent that I am the parent or official guardian of the child listed
below, and hereby consent and grant permission to Accelerate Learning, Inc., and any of its
agents or representatives to take photographs or videos of me and or my child, and to use
such photographs or videos, in association with my and or his/her participation in
STEMscopes activities. Further, I grant Accelerate Learning, Inc. permission to use any or all
written statements, abridged statements, or works that I have, or my child has, made as a
participant of STEMscopes activities. I further understand that these videos, photographs, or
writings or portions thereof may be in the public view and may have my or my child’s name or
likeness associated with them. I grant Accelerate Learning, Inc. and its agents and
representatives a worldwide, perpetual, irrevocable, royalty-free, fully paid, transferable, and
sub-licensable license to use any of the aforementioned items for STEMscopes and
STEMcoach.com publicity, commercial purposes, or documentation purposes, including
creating derivative works of any of the above.
I consent that I and my child will receive no remunerations in connection with this
agreement, and I release Accelerate Learning, Inc., its affiliates and any of their respective
directors, officers, employees, agents and representatives from any future claims as well as
from any liability arising from the this agreement, including the use of the aforementioned
photographs, videos, writings, statements or works.
_________________________________________________________________
Child Full Name
_________________________________________________________________
Parent / Guardian Full Name
_________________________________________________________________
Address
_________________________________________________________________
City / State / Zip
_________________________________________________________________
Phone
_________________________________________________________________
Parent / Guardian Signature
Date (Day/Month/Year)
Accelerate Learning Inc. – 2015 Media & Print Release
5177 Richmond Ave, Suite 1025 | Houston, TX 77057 | (800) 531-0864
acceleratelearning.com