Social Media Photo Release Form

Social Media Photo Release Form

If you are 18 years or older, you do NOT need to fill in the sections for "Child's Name" or "Child's Parent Name". Fill your name in the "Participant (if over 18 years old)" sections.
Instagram: @blackbarnfarmtherapy & @bewellbewildwrestling

Facebook: Be Well at Black Barn Farm & Be Well + Be Wild Wrestling

TikTok: @blackbarnfarmtherapy

Website: https://www.bewellatblackbarnfarm.com/
Child's Name

First NameLast Name
Child's Parent Name

First NameLast Name
Participant (if over 18 years old)

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization, Release, and Consent
Disclaimer: Be Well at Black Barn Farm LLC's social media platforms are strictly used to highlight the journeys of its animals and visitors together on the farm, its services offered, recognitions, and various mental health resources.
What is okay with you? (select one)*

YES, you CAN use my picture or my child's picture for professional social media, website, and pamphlet/poster use.YES, you CAN use a picture ONLY if my face or my child's face is NOT showing for professional social media, website, and pamphlet/poster use.NO, you CANNOT use my picture or my child's picture for professional social media, website, and pamphlet/poster use.
Please select all that apply:

I authorize and grant Be Well at Black Barn Farm LLC to take photos of myself/my child regarding my experiences with them.I grant Be Well at Black Barn Farm LLC to use photos taken of myself/my child's photos on Facebook, TikTok, Instagram, and other social media platforms (ex. Website).I agree that the photos belong to Be Well at Black Barn Farm LLC.I understand that I will not receive any monetary compensation.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Social Media Photo Release Form

Authorization, Release, and Consent