FA - 55

10 October 2018
Rev. 0

NAMEI POLYTECHNIC INSTITUTE

123 A. Mabini St. J-Rizal, Mandaluyong City
COLLEGE DEPARTMENT

STUDENT MEDIA CONSENT AND RELEASE FORM

I, the undersigned, hereby authorize the School and its employees, representatives, and
authorized media organizations to print, photograph, and record me for use in audio, video,
film, or any other digital or printed media.

I am fully aware that I will not receive any monetary compensation for my participation.

I release the school, its Board of Trustees, employees, and other representatives from any
liabilities, known or unknown, arising out of the use of this material.

I certify that I have read the Media Consent and Release Form and fully understand its terms
and conditions.

Name of Student:
Signature:
Date: