PHOTO RELEASE FORM

Louisa Baptist Church

305 East Main Street

Louisa, VA 23093

(540) 967 - 1364

I hereby grant permission to Louisa Baptist Church to use my photograph(s) on its World Wide Web site or in other official church printed publications without further consideration, and I acknowledge the church’s right to crop or treat the photograph(s) at its discretion. I also acknowledge that the church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date. I also understand that once my image is posted on the church’s website, the image can be downloaded by any computer user. Therefore, I agree to indemnify and hold harmless the church, its trustees, pastor, associate pastors, deacons, its members and designees from any claims arising out of the use of my photograph(s). The church reserves the right to discontinue use of any photograph(s) without notice.

Name: __________________________________

Date: ___________________________________

Address: ________________________________

________________________________

Phone: __________________________________

E-mail: __________________________________

Signature: _______________________________

If the above named person is less than 18 years old, the form must be signed by a parent or guardian.