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Media Release Form
Media Release Form
First Name
(Required)
Last Name
(Required)
Child's Name (if applicable)
I agree that Child and Family Agency of Southeastern CT, Inc. owns the information and all copyrights. The rights of Child and Family Agency of Southeastern CT, Inc. to use the Information, in whole or in part, includes the option to change the information (i.e. name) to safeguard my privacy. I authorize Child and Family Agency of Southeastern CT Inc. to photograph and video me and/or my child(ren) or use videos provided for the purpose of marketing, fundraising, advocacy to increase public knowledge about CFA’s programs
(Required)
Yes
No
I understand that I can choose whether I want my name or my child(ren)’s name used.
(Required)
Yes
No
If no, how would you like to be identified in marketing:
If any quotes are to be used in print, I understand that I will be asked for my explicit consent.
(Required)
Yes
No
I understand that I am not required to sign this form in order to receive CFA services
(Required)
Yes
No
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.
(Required)
Yes
No
I understand that I may revoke or discontinue this authorization at any time by notifying the affiliate agency in writing. It will be effective for all ongoing usage of the material.
(Required)
Yes
No
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
