Release Form

  • Student Information

  • Father's Information

  • Mother's Information

  • Additional Information

  • Dismissal Permission:

    Persons permitted to dismiss / pick-up this child.
  • Dismissal Permission

    Persons NOT permitted to dismiss / pickup this child
  • Family Status

    If a parent who has exclusive custody of his/her child wishes the program to not release the child to the non-custodial parent, the custodial parent must provide Tech Town with a copy of the divorce decree or separation agreement which restricts the access rights of the non-custodial parent.
  • Date Signed
  • Please print and fill out this Medical Information Card and present during check-in at Tech Town. Medical Information Card
  • Media Release

    I, the undersigned, on my own behalf and for those who claim under, through or for, me, and on the behalf of the represented minor hereby grant the absolute right and permission to TechTown Foundation, Inc. and The Chattanooga Public Library to take photographs, slides, video, film footage, motion pictures, and/or audio recordings of me or the minor and to copyright, use, publish, alter and distribute the same. I hereby release TechTown Foundation Inc. and The Chattanooga Public Library, its officers, employees, agents, successors and assigns from any suit, claim or demand relating to or resulting from the use of my or the represented minor’s name, likeness, voice, or any combination thereof; and agree to indemnify and hold each of them harmless from all loss, damages, claims or demands growing out the enforcement or attempted enforcement of any suit, claim or action arising out of, or occasioned by the use of such audio and/or visuals. In granting such permission, I hereby relinquish any of my or the represented minor’s right, title or interest in such photographs, slides, video, film footage, motion pictures and/or audio recordings and grant TechTown Foundation Inc. and The Chattanooga Public Library permission to publish, exhibit or use such audio and/or visuals for any purposes, subject only to the exceptions listed below, if any. Further, I waive any of my or the represented minor’s claims that we have, now or at any date in the future, in the nature of a right of publicity or right of privacy based on any use of either of our image, likeness, voice, or name in connection with any audio or visual works associated with this agreement.
    I acknowledge and agree that this document shall be interpreted according to the laws of the State of Tennessee, and that all claims relating to this document must be brought, if at all, in the federal or state courts located in the Hamilton County, Tennessee.
    I, the undersigned, certify that I am 18 years or older and that I am a guardian of the minor and have read this release and understand all its terms. I execute it voluntarily with a full knowledge of its significance.
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