Southport Presbyterian Church
1427 Southview Dr., Indianapolis, IN.
(317-536-7250)

Web Release Form

Name:_______________________________________ Birthdate :____/____/_____

Address:_____________________________________ Phone:________________

City:________________________ State:___________ Zip Code:______________

I hereby give Southport Presbyterian Church of Indianapolis, Indiana and/or representatives of Southport Presbyterian Church of Indianapolis, Indiana the permission to place the following information on the Southport Presbyterian Church's Web Site:

I agree to permit our/my e-mail address to be posted on Southport Presbyterian's website as related to an SPC event or activity. _____YES_____NO

I agree to permit our/my minor child's likeness to be used on Southport Presbyterian's website, as related to an SPC event or activity. _____YES_____NO

I absolve Southport Presbyterian Church of Indianapolis, Indiana and its representatives from liability in acting on my behalf in this regard.

Parent/Adult Signature:________________________ Date:____/____/______
Child's Name:______________________________
Relationship:_______________________________