Media Release Form

Media Release Form

This from is to be filled by the participant.
I First Name* Last Name* give consent to Decent Care to use and retain
the image/ video is attached for advertising purposes including, Decent Care’s
website, Social Media (Facebook, Instagram, Twitter), and print advertising
material.

I understand that I may withdraw this consent at any time by advising Decent Care and my photo/video will be removed or destroyed at this time.

I understand that by giving consent, Decent Care can use the image/ recordings to promote their activities. Decent Care may reproduce the image or video in any form, in whole or part, and distribute it by any medium including printed material, the internet, or multimedia.

I understand that Decent Care:
Will not pay me for giving consent or for the use of this image or recording
Will return or destroy images or recordings if I withdraw my consent
Date*

MonthDayYear
Date
Plan nominee/Guardian: (where applicable)

First NameLast Name
Signature of the participant*

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Upload Photo*

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