Photo and Media Consent

The KS Deaf-Blind (KSDB) Project provides free technical assistance to families and service providers serving students with combined hearing and vision loss birth to 21 years old in KS; funded by the U.S. Department of Education’s Office of Special
Education Programs. The KSDB Project is an extension of the Field Services of the KS State School for the Blind (KSSB).

The KSDB Project requests your permission to use videos/photos/audio recordings of you or your child as part of our outreach activities and for similar activities by our partner organizations such as the National Center on Deaf-Blindness (NCDB), KC Blind All-Stars Foundation (KCBAS), KSSB, Helen Keller National Center (HKNC), Kansas School for the Deaf (KSD).

The purpose of these efforts is to increase awareness of our services, improve the skills and knowledge of service providers and families. Examples of products and services in which videos/photos/audio recordings may be used include websites, social media, conference presentations, television, training modules,
and publications (electronic/print).

Media Release for:

First NameLast Name

Permission:
By signing below, I understand and acknowledge that:
• No payment shall be made to me or my child for the use of the photos/videos/audio recordings.
• My permission is given without coercion or duress.
• This permission remains in effect until such time as I notify the KSDB Project in writing that I wish to revoke it for future projects.
• I release the KSDB Project, KSSB, KCBAS, HKNC and NCDB, and its employees, officers, and directors from any and all liability relating to any and all claims, including but not limited to, claims of defamation, libel, invasion of privacy and
appropriation of name and/or likeness. I release the aforementioned entities and their employees, directors, and officers and from any and all contractual claims including but not limited to personal property rights resulting from the use of the photos/videos/audio recordings.
• I am the person named above or I am the parent/guardian of the person named above.
• I understand that these images can be copied and transmitted by others connected to any social media site without KSDB Project’s knowledge and hereby release and discharge the KSDB Project, KSSB, KCBAS, KSD, HKNC, and NCDB from any and all claims listed in this form.

By signing below, I give my permission to the KSDB Project, KCBAS, KSD, NCDB, HKNC, and KSSB for use of photos, videos, and audio recordings as described above

Date of Signature

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.

If under 18 years old or under guardianship, parent or guardian signature.