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' •a <br />Parent/ Legal Guardian <br />Permission/ Release Form <br />I give my permission for my son/daughter to seek the position of a Youth Member to the <br />Youth Advisory Council of the City of South Bend, Indiana. If selected, I will make sure <br />that my son/ daughter will make the necessary personal and time commitments necessary <br />to serve the youth of our community. I further understand that as a member of the Youth <br />Advisory Council my son/ daughter may have photos, film, digital imaging, videos, <br />verbal and written statements of his or her likeness for promotional, web usage or other <br />uses associated with the Youth Advisory Council. To that end, I grant permission for <br />such usage. <br />(Parent/ Legal Guardian, signature) <br />In case of emergency: <br />Name: <br />Address: <br />(Date) <br />Relationship: <br />Home phone: Work phone number: <br />Cell phone number: <br />