Media Release Form

Music by Heart is a nonprofit music-education organization based in San Francisco. We are delighted to partner with schools to deliver a tailored Jewish education music program that teaches music fundamentals while helping students foster their creativity and explore Jewish culture. More information about our organization can be found at

To help Music by Heart grow, we kindly ask that you grant us permission to use images or videos of your student participating in the program by completing this media release form. As specified below, we would only use this media to promote Music by Heart, and you may opt out at any time.


    Choose Your School

    I certify that I am the parent or guardian of I hereby authorize Music by Heart, a California nonprofit organization, to use Student’s voice, image, or likeness (“Likeness”) in materials promoting or advertising Music by Heart’s products or services, including Music by Heart’s website and social media. By granting this authorization, I hereby release and forever discharge Music by Heart, its officers, agents, and employees from any and all claims and demands arising out of or in connection with the use of Student’s Likeness, including but not limited to any and all claims for violation of publicity rights, invasion of privacy, defamation, or infringement of copyright.

    I acknowledge that this authorization can be withdrawn at any time by sending an email to with the subject line “Media Opt-Out Request,” the body of which email should include the Student’s full name, grade, and student identification number. I agree that the release of claims specified above will be forever enforceable in connection with any use of media containing Students’ Likeness, as long as the use is consistent with the terms of this release and occurs between the date I signed this release (as indicated below) and the date corresponding with 14 calendars days after I send a media opt-out request in the form described above.