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Hearts & Minds - Information for ChangeSM

Our World - Our Future: Youth for ChangeSM
Consent Form for Parents/Guardians

Dear Parent or Guardian,

Hearts & Minds welcomes the participation of your child in the program, Our World - Our Future: Youth for ChangeSM. Children and youth of all ages are creating thought-provoking, inspiring posters, essays, poetry and other works of art to be seen locally and internationally through our website and other media. This program is in New York City and eventually will expand all over the world.

We plan to film and/or photograph the participants and their artwork to raise awareness of poverty, the environment or other important issues in NYC and around the world, and also to support and promote Hearts & Minds' public service.

Hearts & Minds Network, Inc. is an all-volunteer, nonprofit 501(c)(3) tax exempt organization that uses mass communication to promote self-help, volunteering and community service. Our work empowers people all over the world to work on poverty, the environment, human rights, democracy, addictions and other important issues.

Founded in 1996, we use mass communications to inspire, motivate, inform and empower as many people as possible - in New York City, nationwide and beyond.

Our website - www.change.net - provides resources, links and practical advice that enable millions of people worldwide to help themselves and others in need. We bring together young volunteers and experienced professionals to help solve persistent social problems.

We appreciate your interest in helping us help others.

Please carefully review the permission form below. If you have any questions, feel free to ask. If agreeable, please fill out and sign. Thanks.


Bill Blackman

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Hearts & Minds - Information for ChangeSM

Our World - Our Future: Youth for ChangeSM

Release Agreement

This is an Agreement between Hearts and Minds Network, Inc. and all individual(s) specified below.

I, ______________________________, hereby give irrevocable, exclusive and unrestricted rights and full permission to Hearts and Minds Network Inc. ("Hearts & Minds") to use, re-use, copy, edit, alter, transform, distort, publish, license, assign and distribute words and images including photographs, audio and video recordings of my (child, children) and their artwork, spoken and written words (collectively called "the work"), done in any programs clearly sponsored by Hearts & Minds, Youth for Change and/or the End Poverty Campaign.

This Agreement is for the benefit of Hearts & Minds (a nonprofit, public service organization), its agents, licensees, representatives and assigns and shall be binding upon me and my heirs, legal representatives and assigns.

I understand that Hearts & Minds may decide in which media and in what manner the work will be published. The released artwork can be used for illustration, art, promotion, public relations, fundraising, advertising, trade, stock photography, promotion of any goods or services or any purpose whatsoever in any media now known or existing in the future.

Hearts & Minds shall be considered the author of the artwork under all copyright law of New York State and the USA and shall have ownership of the works. I release, discharge and agree to hold Hearts & Minds harmless resulting from any injury or accident, regardless of cause, from any liability arising out of this Agreement. Any dispute under this Agreement shall be decided by arbitration.

This Agreement can only be modified in writing and only when signed by both parties. I am at least 18 years of age* and have the legal right and authority to contract for this Agreement and my (child, children).

I affirm that I have read carefully and have agreed to the terms in this Release Agreement.

Please print:

My full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Street: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Apt. #: |__|__|__|__|

City: |__|__|__|__|__|__|__|__|__|__|__|__|__|__| State: |__|__| Zip Code: |__|__|__|__|__|

E-Mail (optional): |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|.|__|__|__|__|

Phone number(s): |__|__|__| - |__|__|__| - |__|__|__|__| and |__|__|__| - |__|__|__| - |__|__|__|__|

Signature: _______________________________________________

My age (not required if I am 18 or older)*: |__|__|   Date: ____/____/___

If you do not want you or your participants to be identified by last name, place your initials here: |____|

Participant(s) under age 18 with same parent or guardian* (please print):

1. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

2. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age:|__|__|   Signature: _______________________________________________

3. Full name: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Age: |__|__|   Signature: _______________________________________________

*If there is a different parent or guardian, please use a separate form. Thank you!

Feel free to Contact Us if you have any additional questions or concerns:

Logo and link for the Youth for Change programHearts & Minds lightbulb logo links to home pageHearts & Minds
165 West 105th Street
New York, NY 10025
E-mail: [email protected]

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This web page and entire website Copyright: 1997 - 2015 by Hearts and Minds Network, Inc.
http://www.heartsandminds.org/youth/release.htm - online August 20, 2003, latest changes June 15, 2010