I hereby authorize the Milton J. Rubenstein Museum of Science & Technology/ Greater Syracuse Scholastic Science Fair to take/use still or video photographs of myself, either with or without my name, for: publications, photo contests, publicity and/or public relations. I understand these images may be used in television, newspapers, Web sites (electronic form), magazines, travel publications, posters or in-house publications.

I waive any rights I may have to such images, as well as the privileges of inspecting them, approving them or determining their final disposition.

Name (print): ___________________________________________________________

*Parent's Name (print): ___________________________________________________

*Signature: _____________________________________________________________

*parent/guardian required if person is under 18 years of age.

Staff Signature: ____________________________ Date: ______________________

Return completed form to PR Department

I do not give permission for my child's images to be used in any of the above listed manner.

Parent's Name (print): ___________________________________________________

Signature: _____________________________________________________________

Revision 11/5/05