Permission to Post Name, Picture, and MIDI or Audio File Recording on the Piano Plus Web Site of Betty Chester

I, _____________________________________, (parent/guardian), give permission for

_______________________________________, (student), to record a piano work on a

MIDI keyboard and to have that performance

, along with a his/her name and digital photo, posted on a web site hosted by Betty Chester and accessible on the Internet. I am over the age of 21 and, if signing on behalf of a minor dependent, I have the right to enter into this agreement on behalf of my minor dependent. To the best of my knowledge, the

performance rights to the piano

work are in the public domain.

___________________________________
Signature

___________________________________
Name (print)

___________________________________
Street Address

___________________________________
City, State, Zip Code

___________________________________
Phone Number

___________________________________
Date

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