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Student Name

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Grade Level

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Homeroom Teacher

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Parent or Guardian Name

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Phone Number

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Email

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Emergency Contact Name

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Emergency Contact Phone Number

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Second Emergency Contact Name

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Second Emergency Contact Phone Number

I grant permission to Georgetown College to release photos of my child for use in promotional materials including but not limited to brochures., PowerPoint presentations and the Georgetown College website and Facebook page. I understand that Georgetown College will not identify my child by name for use in promotional materials. I also understand that I can revoke my permission in writing at any time for photos released electronically, but I am unable to revoke permission for images included in print materials. By giving permission to photograph my child I agree to indemnify, defend and hold harmless the members of Georgetown College, its employees or agents from and against any and all claims and liabilities from this publishing.

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Please type your name as signature authorization for Art Club and photo permission: