Name *

First Name

Last Name

I, the undersigned, do hereby give permission to Parent Advocates for Choice in Education (“PACE”) to use video interviews, written story submissions, and photographs of me or my child provided to PACE. I give PACE permission to use and publish any and all recorded or submitted story content on their website and in any material promoting PACE’s programs or for any other lawful purpose. I hereby hold harmless and release and forever discharge PACE from all claims, demands, and causes of action which I have or may have by reason of this authorization. *

Video interviews, written story submissions, and photographs of me will remain the property of the Parent Advocates for Choice in Education and will not be sold for profit or used for commercial purposes. Any proceeds resulting from the use of the videos, photographs, and written story submissions will be used only to support the mission of PACE. I understand that I have voluntarily provided photographs, interviews and story submissions and that neither myself nor anyone within my party will receive payment for future use of the photographs, interviews or story content.

By checking this box, I give PACE permission to publish my story on their website and in any promotional material.

I am willing to appear in PACE videos to share my school choice story.

I certify that I am 13 years of age or older.