Web Privacy Release Form


This form should used if any personal information is to be used on the SPC website. It simply states for our records that you are aware of the use of the specified information and that you have given SPC permission to post that information on the website.
Print this form and return it to SPC at the address below.

Southport Presbyterian Church
7525 McFarland Blvd., Indianapolis, IN 46237.
(317-534-2900)

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:_______________________________