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Media Release

AUTHORIZATION for PHOTOGRAPHY, VIDEO, AUDIO, TESTIMONIAL, AND PUBLIC RELEASE

Tennyson Center for Children has been providing services to children and families for over 100 years. In order to continue these services, the agency produces materials for educational and fundraising purposes, some of which relate to the clients TCC serves. These materials may be distributed to the general public, donors, or the media.

The signing of this release form is strictly voluntary and will not affect the student’s participation in any clinical or school classroom.

At Families Together we use your experiences to help us recruit excellent people for our families and welcome new families to our mission. We ask that anyone who participates in Families Together sign a release to allow us to use your stories.

Please select one of the following four options and initial as parent/legal guardian that is signing the authorization:

Select one of the following options for authorization of photography, video, audio, testimonial and public release.*

I give permission for photographs, testimonials, audio, and/or video to be taken of the above named client. I understand that these materials may be used by Tennyson Center for Children for educational and fundraising purposes, including distribution to the general public, donors, or the media. I give permission for photographs, testimonials, audio, and/or video to be taken of the above-named client but the client must be deidentified before public use. *Deidentified means that the face of the client will be blurred. I understand that these materials may be used by Tennyson Center for Children for educational and fundraising purposes, including distribution to the general public, donors, or the media. I give permission for photographs, testimonials, audio and/or video to be taken of the above named client. I understand that this selection will limit the use of these materials solely for distribution inside of Tennyson Center for Children. I do not give my consent for the taking of any photographs, testimonials, audio and/or video of the above named client.

Exceptions to Authorization:

This release may be revoked by notifying Tennyson Center for Children in writing to the client’s primary therapist or the Families Together staff. Any revocation will not affect materials produced or distributed prior to receipt of the written revocation of consent.

Signatures

Client Name (Print)*

First Name

Last Name

Signature*

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Date*

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Media Release

Signatures