NYC Soccer academy Spring Break

Departure Release Form

Child May Only Be Released to the Following:
Children will only be released to parent/guardian listed on this form and to individuals whose names appear below. Individuals may be required to present photo identification when picking up children from NYC Soccer Academy.

	Name of Camper
	Parent or Legal Guardian
	Date
	1 Name
	1 Phone
	2 Name
	2 Phone
	Special Instructions

	Participation in or Use of Photograph
	For valuable consideration, I do hereby authorize the Trustees of Columbia University in the City of New York (“Columbia”), and those acting pursuant to its authority to: a. Photograph me for use in one or more publications relating to NYC Soccer Academy b. Exhibit or distribute the photographs and / or my likeness in whole or in part in any medium, whether now existing or later created, including digitally and online, without restrictions or limitation for any educational or promotional purpose which Columbia, and those acting pursuant to its authority, deem appropriate. I hereby release any and all rights I may have in such photographs, including intellectual property rights, right of publicity and all other rights.
	Name of Camper
	Parent or Legal Guardian
	Date

NYC Soccer Academy, Columbia University, NY, NY 10027

Departure Release Form

Participation in or Use of Photograph