Parent Release Form for Media Recording

I, the undersigned, do hereby grant or deny permission to [Organization Name] to use the image of my child, _________________________________, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the [Organization Name] website.

☐	Deny permission to use my child’s image at all.
☐	Grant permission to use my child’s image in the following ways (mark all that apply):
☐ Limited usage: I want my child’s image used within the [Organization Name] setting only (not in the larger community). ☐ Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within [Organization Name] or in the larger community. One example of this could be videos in parent education classes. ☐ Limited usage: I want my child’s image used on printed materials only (no digital or video use). ☐ Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by [Organization Name] for a variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images.

Parent/Guardian signature	Date

Please make a copy of this form for your own records and mail or fax the original to:

[Recipient Name]

[Title]

[Organization Name]

[Street Address]

[City, ST ZIP Code]

[fax number]

If you have questions, contact [Name] at [phone number].