Forms – Child First Media Consent

Child First – Consent to Photography and Video

Child First Consent to Photo and Video 2020-09-25

Child First

CONSENT TO USE PHOTOGRAPH AND VIDEO
Child Name*
First Last
Child Date of Birth*
MM slash DD slash YYYY
Are there any other children?*
- Yes
- No
Child Name (2)
First Last
Child Date of Birth (2)
MM slash DD slash YYYY
Child Name (3)
First Last
Child Date of Birth (3)
MM slash DD slash YYYY
Copyright and Information Agreement*
- I agree that the Child First affiliate agency and Child First, Inc. jointly own the information and all copyrights. The rights of Child First, Inc. and The Child and Family Agency of Southeastern Connecticut (affiliate agency) to use the Information, in whole or in part, includes the option to change the information in order to safeguard my privacy.
I authorize the Child and Family Agency of Southeastern Connecticut and Child First, Inc. to photograph and videotape me and my child or children and other family members for purposes of (check all that apply):*
- in-person professional training (including limited historical information)
- online professional training (including limited historical information)
- increasing public knowledge about Child First (including external publication, television, or internet)
- marketing and fundraising
- I understand that I can choose whether I want my name and my child or children’s names used. If any quotes or related information about my family are to be used in print, I understand that I will be asked for my explicit consent.
- I understand that I am not required to sign this form in order to receive services from Child First or other services at the affiliate agency.
- I understand that the photographs and videos used or disclosed under this authorization may be reused by the recipient and may no longer be protected by the HIPAA privacy regulations.
- I understand that I may revoke or discontinue this authorization at any time by notifying the affiliate agency in writing. It will be effective on the date the agency notifies Child First, Inc. (except to the extent action has already been taken based on my earlier authorization).
Acknowledgement*
- By signing below, I acknowledge that I have read and understand this authorization.
Parent/Guardian signature*
Date*
MM slash DD slash YYYY
Please click SUBMIT when complete

Forms – Child First Media Consent

Child First – Consent to Photography and Video

Child First

CONSENT TO USE PHOTOGRAPH AND VIDEO

Please click SUBMIT when complete