WEB PRIVACY RELEASE FORM

St. Andrew Lutheran Church

1605 Neuse Blvd.

New Bern, NC 28560

(252.637.5879)

Name: _______________________________________________

Address: _____________________________________________

City: __________________________ State: ________________ Zip Code: ________

Daytime Phone Number: ___________________

Evening Phone Number: ____________________

I hereby give St. Andrew Lutheran Church of New Bern, North Carolina and /or representatives of St. Andrew Lutheran Church, the permission to place the following information on the St. Andrew Lutheran Church Web Site:

I agree to permit our/my e-mail address to be posted on St. Andrew’s website as related to a St. Andrew Lutheran Church event or activity. ____YES ____NO

I agree to permit our/my minor child’s likeness to be used on St. Andrew’s website, as related to a St. Andrew Lutheran Church event or activity. ____YES ____NO

I absolve St. Andrew Lutheran Church of New Bern, North Carolina and its representatives from liability in acting on my behalf in this regard.

Please Print Parent/Adult Name: _________________________________

Parent/Adult Signature: _______________________________ Date: ___/ ___/ ____

Please Print Child’s Name: _____________________________

Relationship: _______________________________