TANEY COUNTY HEALTH DEPARTMENT

TANEY COUNTY HEALTH DEPARTMENT
PHOTO & INTERVIEW RELEASE

I give permission for photographs/video of me and/or my child(ren) listed below, and any corresponding interview, to be used as deemed fit by Taney County Health Department.
Your Name*
Child's Name
Child's Name
Child's Name
CHOOSE ONE

You may identify me/us by name
Your Initials
Please DO NOT publish my/our name(s)
Your Initials
Email (used ONLY to send you a copy of this completed form)
example@example.com
Signature of Participant or Participants Legal Guardian*

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Date*

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