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Do you have any privacy preferences or needs? For example, you prefer only your or your child's your first name be used.
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I consent under the condition the folllowing privacy conditions are met:
My image is obscured to not reveal my identity
Only my first name is used
A pseudonym/fake name is used to protect my identity
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I consent under the condition the folllowing privacy conditions are met:
My child's image is obscured to not reveal my identity
Only my child's first name is used
A pseudonym/fake name is used to protect my child's identity
My child's voice is masked to protect their identity
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As a nonprofit, we rely on contributions from individuals and organizations. Can we use this story in our fundraising efforts?
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I understand this media release form grants indefinite permission to use this story unless I contact ZERO TO THREE and request otherwise. Instructions on how to contact the organization will be emailed to me when I submit this form.
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I have the right to use the Content for personal and non-commercial use only. I hereby release, waive, and discharge ZERO TO THREE and/or its affiliates, agents, successors and/or assigns from any and all demands or claims that I or any third parties have or may have arising out of or in connection with the foregoing use of the Content or Personal Information.
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Child's Name:
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First Name
Last Name
Address
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Street Address
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example@example.com
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By signing this consent, I am confirming that I am 18 years of age or older and the parent/guardian of the child indicated.
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