Student Information Student Last Name Student First Name Student Age Parent/Guardian Information Parent/Guardian Last Name Parent/Guardian First Name Parent/Guardian Email Photo/Model Release Photo Release Statement For mutually agreed upon consideration, the receipt and sufficiency of which is hereby acknowledged, I, the undersigned, irrevocably authorize Longwood Gardens, Inc. (“Longwood Gardens”), its employees, affiliates, legal representatives, successors, agents, assigns and all those acting on Longwood Garden’s behalf or commissioned to act on Longwood Gardens’ behalf (“Authorized Persons”) to take any form of pictorial, video and/or sound recordings of me (the “Materials”), with right of Longwood Gardens to edit same and to put the finished product to any lawful use that Longwood Gardens may choose in perpetuity and throughout the world. I specifically consent to the use and display of the Materials with other images, text, graphics, film, audio, and audiovisual works. I acknowledge and agree that said Materials may be altered or modified without any restrictions, whether by traditional photographic techniques or digitally. I further grant Longwood Gardens the right and privilege to give, sell, lend, transfer, and exhibit the original Materials or copies thereof to any individual, business, or publication, or to any of their assignees. To the fullest extent permitted by applicable law, I hereby irrevocably waive all legal and equitable rights relating to all liabilities, claims, demands, actions, suits, damages, and expenses, including but not limited to claims for copyright or trademark infringement, infringement of moral rights, libel, defamation, invasion of any rights of privacy (including intrusion, false light, public disclosure of private facts, and misappropriation of name or likeness), violation of rights of publicity, physical or emotional injury or distress, or any similar claim or cause of action in tort, contract, or any other legal theory, now known or hereafter known in any jurisdiction throughout the world (collectively, “Claims”) arising directly or indirectly from the Authorized Persons’ exercise of their rights under this Release or the production, exhibition, advertising, promotion, exploitation, or other use of the Materials, and whether resulting in whole or in part from the negligence of Longwood Gardens or any other person, covenant not to make or bring any such Claims against any Authorized Persons and their agents, employees, and representatives, and forever release and discharge the Authorized Persons from liability under such Claims. I agree that this Release cannot be terminated, rescinded, or modified, in whole or in part. THIS RELEASE PROVIDES LONGWOOD GARDENS WITH YOUR ABSOLUTE AND UNCONDITIONAL CONSENT, WAIVER, AND RELEASE OF LIABILITY, ALLOWING LONGWOOD GARDENS TO PUBLICIZE, COMMERCIALLY EXPLOIT, AND OTHERWISE USE YOUR LIKENESS AND NAME AS SET OUT ABOVE. BY SIGNING, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS RELEASE AND THAT YOU ARE GIVING UP SUBSTANTIAL LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE LONGWOOD GARDENS. The undersigned acknowledges that he/she has read this Release, understands its full meaning, and has executed this Release with full understanding of this Release’s meaning. Authorization Checkbox I consent to the above statement I do not consent to the above statement Authorization Signature Parent/Guardian Signature Authorization Date What code is in the image? Enter the characters shown in the image.