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Permission Form

1. Date

Date

2. Your Name:

First Name*

Last Name*

Company

Address*


City*

State*
Postal Code*

Country*
Email*

Day Phone*

Evening Phone

3. Subjects name:


4.


I, the above named parent or guardian of the above named minor child subject hereby grant and assign to Bumba Bella and their legal representatives the right and permission to publish my child’s photographic image for the specific purpose of publication on their website www.BumbaBella.com. I also permit the use of any text or printed material in connection therewith. In giving my consent, I hereby release, discharge, and agree to hold harmless Bumba Bella, their officers, employees, agents, legal representatives, designees, and all persons functioning under Bumba Bella’s permission or authority, from any and all responsibility or liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise including without limitation any claims for libel or invasion of privacy. I understand that I will receive no payment or compensation other than that indicated in the following paragraph should any photographs of my child be used.

[quote]
If you submit a satisfactory picture of your child wearing an item sold by Bumba Bella and allow us to use the picture on our web site, we will give you a REFUND of 25% credited on the credit card you used to purchase the item.
[unquote]

I understand my child’s picture and this release form will be maintained at Bumba Bella. I understand all pictures released to Bumba Bella will not be returned. I understand that I may resubmit another picture along with an updated photo release form.

I understand Bumba Bella has full authority as to which pictures they choose to place on their website. Bumba Bella is not required nor obligated to use any pictures I submit. I hereby relinquish any right that I may have to examine or approve the complete product or products or the advertising copy or printed material that may be used in conjunction therewith or the use to which it may be applied.

I hereby affirm that I am over the age of majority and have the right to contract in my child’s name. I have read the above authorization, release and agreement, prior to its execution. I fully understand the contents thereof. This agreement shall be binding upon me and my heirs, legal representatives and assigns.

I understand that by filling out this form and uploading or submitting a picture or photograph that I am showing my agreement with all the above terms.

5. Upload the picture.

Click to upload a file
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