As the Parent and/or Legal Guardian of , I hereby authorize
the Gabe Fleming Memorial Hockey Scholarship Fund (“the Fund”), and its Board Members, agents and/or
representatives, to use my child’s image and name in all forms and media, for publicity and/or recognition
purposes. Consequently, the Fund may publish materials and photographs, use my child’s name, and make
reference to my child in any manner that the Fund deems appropriate in order to promote the Fund.
I waive the right to inspect or approve versions of my child’s image used for publication or the written copy
that may be used in connection with the images. This authorization is continuous and may only be
withdrawn by my specific rescission of this authorization.
I hereby release the Fund, its Board Members, agents and representatives, from all claims, demands and
causes of action that may result from use of this authorization.
I am the parent or guardian of the minor named above. I have the legal right to consent to, and do consent to,
the terms and conditions of this release.