Fill and Sign the Authorization Parent Form

Waiver, Release and Authorization to Use Names of Parent and Child in Book to be Published Agreement executed on __________________________________ (date) , by ________________________________________ (Name of Releasor) and the Guardian(s) of ________________________________________ (Name of Child) of _____________________ ______________________________________________________________________________ _____________________________ (street address, city, county, state, zip code) , both Releasor and Guardian(s) being jointly and severally referred to herein as Releasors , in favor of ______________________________________ (name of author) of ______________________ ______________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) herein referred to as Author . Whereas, Author is writing or has written a book entitled or to be entitled ____________ ________________________________________________________________ (name of book) , hereinafter called Book; and Whereas, said Book is or shall be an account of (briefly describe what Book deals with, particularly why the names of Parent and Child are being used and are necessary for the Book) ________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________________; and Whereas, Author has used or desires to use the name of ___________________________ ________________ (Name of Releasor) and the name of _______________________________ ______________ (Name of Child) name in said Book ; Now, therefore, for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, Releasor, being of lawful age, hereby expressly releases Author , his publishers, licensees, agents, successors and assigns (hereinafter jointly and severally called Releasees ), from all liability for claims and/or demands arising out of the use of the names of Releasors in Book, including, but not limited to, libel, slander, invasion of privacy or any other claim based on use of the name of Releasors in said Book. Releasors hereby authorizes Releasees to use Releasor’s name in Releasees’ discretion, and to incorporate the name of Releasors into said Book in Releasees’ discretion, and to use any information that Releasors have provided in any way to Releasees in connection with the preparation and/or publication of said Book and in the promotion or advertising relating to the preparation and/or publication of said Book. Releasors further agree to indemnify and save Releasees harmless from any and all claims and liability for damages, losses or expenses of any sort arising from use of the names of Releasors in the writing, making or the publication of said Book. Releasors warrant and agree that they have read and understand the contents hereof, and that they have the right and authority to execute this waiver, release and indemnification. In witness whereof, the parties have executed this Agreement as of the date and year first above written. ________________________________________ (N ame of Child) By: _____________________________________ ____________________________________ Signature of Father as Legal Guardian Signature of Releasor ________________________________________ _ __________________________________ (Printed or typed name) (Printed or typed name) _________________________________________ (N ame of Child) By: _____________________________________ Signature of Mother as Legal Guardian _________________________________________ (Printed or typed name)