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I hereby consent to the use and reproduction by
Pamplin Historical Park of my child's photographic image for future
publication while attending the Pamplin Historical Park history
camp.
I agree not to hold the publication or its agents responsible, under
any circumstance, for any action which occurs as a result of this
advertisement. I understand that my child's photographic images
will become the exclusive property of Pamplin Historical Park and
will be used only for promotional purposes.
I agree that I will not be compensated for the use of my child's
photographic image.
| Date |
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| Child’s Name |
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| Parent/Guardian Signature |
_____________________________________________ |
| Parent/Guardian Printed Name |
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| Address |
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| City, State Zip |
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Print this form, and FAX or mail it to us at: Pamplin Historical Park
6125 Boydton Plank Road
Petersburg,
VA 23803
( 804) 861-2820
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