I hereby authorize the Greater Chambersburg Chamber Foundation (GCCF), its affiliates and sponsors to use my
photographs, image, and voice for the purposes of inclusion in GCCF communication products including, but not limited
to, advertising, outreach, education, fundraising, web content, audio, video, or media coverage. I also authorize GCCF to share the email addresses provided to the GCCF via the application or by other method, among the staff, students and parents of the class.

I understand that I have the right to revoke this authorization in writing by sending a signed letter to the following: Executive Director, GCCF, 100 Lincoln Way East, Suite A, Chambersburg, PA 17201. I acknowledge that a revocation will not impact any action taken before GCCF’s receipt of the revocation in reliance on this authorization.

I understand that I will receive no financial or in-kind compensation in exchange for GCCF’s use or disclosure of this information.

I understand that GCCF may not condition my participation in LFCY on my agreement to sign this authorization.
This authorization will continue for the life of the marketing and communication products for which my information is used.

I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure on multiple occasions in the future by the persons who receive the material and may no longer be protected.

I further agree that my participation in any publication and website produced by GCCF confers upon me no rights of
ownership whatsoever. I release GCCF, its contractors, employees, volunteers, sponsors and all affiliated entities from liability for any claims by me or any third party in connection with my participation.

I understand that I may receive a copy of this form after I have signed it at my request.

GCCF Employee Obtaining Authorization: Robin Harmon, Executive Director

* 1. Student's Name:

* 2. Telephone Number of Parent/Guardian:

* 3. Email Address of Student

* 4. Email Address of Parent/Guardian:

* 5. Birthdate of Student:

* 6. Address:

* 7. Parent or Guardian: By typing my name below, I acknowledge that I understand and agree to the conditions described above in the Communications Release Form.

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