Mike Worobel Martial Arts LLC

Permission to Publish a Picture of a Student

Dear Parent or Guardian,

As you may be aware, Mike Worobel Martial Arts LLC hosts a webpage at:

http://www.mwmartialarts.com/

Occasionally we would like to post a picture of a particular karate event, such as a belt test, tournament, or class. This may involve posting a picture showing a student or group of students participating in the event.

If a student’s picture is used:

• He/she is only identified by first name, if consent is given
• Personal information such as phone number, address, etc. will not be published.
• Information provided will not indicate physical location of a student at a give time other than attendance of an event.

Before posting pictures of students, we require that the parent(s)/guardian(s) sign the consent and release form below.

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Consent and Release

I grant Mike Worobel Martial Arts LLC permission to post pictures of my son/daughter on the Mike Worobel Martial Arts website. I understand these pictures may distinctly identify him or her. I further release Mike Worobel Martial Arts LLC and its employees from liability of any claims, including without limitation, claims for libel, defamation, invasion of privacy and right of publicity, and infringement of proprietary rights, arising out of or relating to the exercise of rights granted under this Consent and Release.

Please check the appropriate permission below which you grant and then sign and date as indicated.

----------- Mike Worobel Martial Arts LLC has permission to post a picture of my son/daughter on its website.

----------- Mike Worobel Martial Arts LLC has permission to post a picture of my son/daughter, and his/her first name, on its website.

----------- Mike Worobel Martial Arts LLC does not have permission to post a picture of my son/daughter on its website.

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Print Name of Student Print Name of Parent(s) or Guardian(s)

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Signature of Parent(s) or Guardian(s) Date

NOTE: This agreement will be in effect for as long the student attends Mike Worobel Martial Arts LLC, and may be revoked at any time by the parent/guardian by contacting Mike Worobel at (603) 964-5886.