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
Your Initials
Your Initials
Email (used ONLY to send you a copy of this completed form)
example@example.com
Signature of Participant or Participants Legal Guardian
Date

MonthDayYear
Date
Relationship to Participant
Should be Empty: