PMR Form

FORM INST-900-GENv.1.
00s2019
PMR
IQA-DPO Control # 190820-101
INSTITUTIONAL QUALITY ASSURANCE OFFICE
PHOTO, MEDIA AND MODEL CONSENT AND RELEASE
NAME OF ACTIVITY: CHRISTMAS LIGHTING CEREMONY
NAME OF PARTICPANT/MODEL: Abby Venice T. Mendoza DATE: Dec. 2, 2022
PURPOSE: PUBLICATION MEDIUM:
Marketing & promotions Print materials, marketing Other _____________________________
/_Documentation & archive collaterals

______________________________________
Posters, tarpaulin, billboards,
Press article & publicity
Printed and/or electronic bulletin ______________________________________
Art
boards
Advertising ______________________________________
/ Digital storage, galleries
Fund-raising
______________________________________
/ Video, audio, multi-media
recording, AVP
/ Online (website, social media

article)
AUTHORIZATION, WAIVER & CONSENT

I give De La Salle Lipa (DLSL), its employees, designees, agents, independent
contractors, legal representatives, successors and assigns, and all persons or
departments for whom or through whom it is acting, the absolute right and unrestricted
permission to take, publish, reproduce, edit, exhibit, project, display or copyright / _ ____
photographic/ recorded images or likeness of me / my child(ren), whether still, single, Agree Disagree
multiple or moving or in which I / they may be included in whole or in part, in color or
otherwise, through the publication media stated above at any campus or elsewhere, for
the purpose(s) stated above
I waive any right that I may have to inspect and approve the finished product that may be
used or to which it may be applied now and/or in the future, whether that use is known to __/__ ____
Agree Disagree
me or my child(ren) or unknown for as long as it is within the legitimate interest of DLSL
I acknowledge that my / my child(ren)’s participation is voluntary and that I will not receive
financial compensation associated with the taking or publication of these photographs or __/__ ____
Agree Disagree
images
I release and hold harmless DLSL from any reasonable expectation of privacy or ____ ____
confidentiality associated with the images or likeness specified above Agree Disagree
I understand that DLSL shall have complete ownership of the property in which the
photographic images appear, including copyright interests and I acknowledge that I have __/__ ____
Agree Disagree
no interest or ownership in the property or its copyright
I understand that DLSL may become part of DLSL’s archives and stored in perpetuity and
that DLSL may use the photographic images to provide visual insights to future __/__ ____
Agree Disagree
generations of Lasallians
I waive any right to royalties or other compensation arising from or related to the use of __/__ ____
the image now and/or in the future Agree Disagree
I release DLSL, its employees, designees, agents, independent contractors, legal
representatives, successors and assigns, and all persons or departments for whom or __/__ ____
through whom it is acting involved in the creation or publication of materials, from liability Agree Disagree
for any claims by me or any third party in connection with my / my child(ren)’s participation
____ I certify that I am at least 18 years of age and that
____I am below 18 years of age and I am joined herein by my
this release is signed voluntarily, under no duress, and
parent or legal guardian and that this release is signed voluntarily,
without expectation of compensation in any form now
under no duress, and without expectation of compensation in any
and/or in the future
form now and/or in the future
________________________________________
Signature over Printed Name
Date signed: ________________________________

__/__ Permission given to identify by first and last name Abby Venice T. Mendoza
Signature over Printed Name of Child Under 18
____ Please identify by first name only
____ Please do not identify by name
Norilyn T. Mendoza
Signature over Printed Name of Parent / Guardian
Date signed: 11/26/22

__/__ Permission given to identify by first and last name
____ Please identify by first name only
____ Please do not identify by name

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FORM INST-900-GENv.1.

/_Documentation & archive collaterals

/ Online (website, social media

AUTHORIZATION, WAIVER & CONSENT

Date signed: ________________________________

Date signed: 11/26/22

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