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Extreme Dreams USA Release Form


I hereby authorize and grant permission to the Extreme Dreams USA Org to use my child’s photographic or video image. I agree that such reproduction may be edited as desired and used in whole or in part for print, audio-visual, multimedia, online, and/or exhibition purposes in any manner or media, in perpetuity, throughout the world. I understand that Extreme Dreams USA Org. will not sell this footage and sole purpose for using the photos or video is to promote the integrity of their company and brand. I understand that I have no rights to any benefits derived therefrom. I recognize that I have the right to enter into the Agreement and that my rights I have granted in this Agreement will not conflict with or violate any commitment or understanding I have with any other person or entity. I agree to indemnify and hold harmless the Extreme Dreams USA Org from and against all claims, losses, expenses and liabilities of every kind including reasonable attorney’s fees, arising out of the inaccuracy or breach of any provision of this Agreement. I expressly release the Extreme Dreams USA Org from any and all claims arising out of the use of my child’s photographic or video image. This Agreement represents the entire understanding of the parties and may not be amended unless mutually agreed to by the parties in writing.


Date: _________________


Parent or Legal Guardian:_______________________________________

Please sign name.


Parent or Legal Guardian:________________________________________

Please print name.


Street Address: ________________________________________________


City: ________________________ State: ________ ZIP: ____________


Phone: (____) ________________Email:_________________________________________




Student Name:__________________________________________________________________


School Name and Grade: Bernal Smith Boys And Girls Club


Sincere thanks,


Richard Hervey


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