Photo/Video Release Form

Date: Click or tap to enter a date.

Child’s Name or Names: Click or tap here to enter text. (parent/guardian must sign this form)

Parent/Guardian Name or Names: Click or tap here to enter text.

Non-OESD Staff Adult’s Name or Names: Click or tap here to enter text.
(non-OESD staff adult must sign this form; fill out a separate form for child/children)

*

Address, City, State Zip Code: Click or tap here to enter text.

Phone: Click or tap here to enter text.	Alternate Phone: Click or tap here to enter text.

The signing of this form is strictly voluntary. I understand that I may withdraw my consent at any time but that I must do so in writing. Please put your initials next to the item(s) below that you DO consent to. Check all that apply.

☐ (check mark for consent) permission to record my photograph,

☐ (check mark for consent) permission to record moving image, and

☐ (check mark for consent) permission to record audio clip;

By giving my permission I waive any proprietary rights I may have to them. I understand that it may be used in a number of ways that will promote the program including on our website, within agency publications or advertising, or shared with media partners.

I ACCEPT ☐

By selecting the “I ACCEPT” button, you are signing this form electronically. You agree your typed, electronic signature is the legal equivalent of your manual signature on this form.

Parent/Guardian Electronic Signature: Click or tap here to enter text. Date: Click or tap to enter a date.
Non-OESD Staff Adult Electronic Signature: Click or tap here to enter text.	Date: Click or tap to enter a date.

I do not wish to have my image or voice released or used for any reason.

Parent/Guardian Electronic Signature: Click or tap here to enter text.	Date:Click or tap to enter a date.
Non-OESD Staff Adult Electronic Signature: Click or tap here to enter text.Date:Click or tap to enter a date.

August 2017