Multi-media Authorization & Release Form

In Perpetuity Photo/Video/Artwork Consent Form

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* Please enter your name:

Provider Name

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* I understand the images of my child care program and/or sound recordings, video recordings, and images of my facility, and surrounding environment may be used for publications, website, Facebook/social media, news media, print media, and any marketing materials. (Please initial)

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* I understand that no images of children will appear in any images without written consent of the parent or guardian. No home addresses, email addresses, or telephone numbers will appear with any images, video and audio recordings, or published work. (Please initial)

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* I understand and agree that Children’s Council may use these images, video, & recordings in subsequent years unless I revoke this authorization by notifying them in writing. (Please initial)

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* Subject to the above conditions, I grant permission for the images of myself, children in my program (with parental consent), sound recordings, videos, and images of my facility may be used by Children’s Council publications, website, social media, news media, print media, and any marketing materials promoting family child care. (Please initial)

Question Title

* I am confirming that I have a signed photo/video release consent form on file from the parents/guardians of any child who appears in photos on my child care program’s website.

Provider Signature (Enter your full name):

Date: