Video/Photograph Release Form – Child Video/Photograph Release Form - Child Child/Children Name* Child/Children DOB* Relationship to the Child / Children* Name(s)* Address* Phone - Home Phone - Cell Reason for Media Use I/we hereby give permission for Christian Family Care (CFC) to use photographs/images of the child/children listed in this form. My relations to this child is listed in this form entry. I/we understand that CFC will be utilizing these photographs to display in our offices and for other lawful venues, such as publicity, illustrations, advertising and Web content for the express purpose of promoting Christian Family Care services. This release also gives Christian Family Care permission to release our family name. I/we also grant CFC, and its representatives the ability to copyright, use and publish the same in print and/or electronically. I/we will notify CFC in writing if we choose for any reason to withdraw permission for CFC to use my/our photographs. CFC shall 120 days after receipt of notice stop any further use of my/our photographs. This release is valid until further notice by the signatory(ies). Date* MM slash DD slash YYYY Signature*CAPTCHA Δ
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