Parental Photo Release Form
For photos submitted to Applied Natural Health
Dear Parent/Guardian,
Thank you for sharing photos of your child with our clinic. We are committed to using these images respectfully and with your full consent. The purpose of sharing these photos is to support and encourage other parents who are seeking help for their children's health and well-being through acupuncture and holistic care.
PURPOSE
The purpose of using these images is to support other parents who are looking for effective and compassionate care options for their children. By sharing these images, we aim to offer hope, guidance, and relatable stories to families who may benefit from acupuncture and natural medicine.
PRIVACY & PROTECTION
- Children's faces will never be shown in any published or shared materials.
- No names or identifying details will be used without additional written consent.
- All images will be used respectfully and in ways that preserve dignity and privacy.
CONSENT
YES, I grant permission to Applied Natural Health to use the photos I have voluntarily submitted of my child in the following ways (check all that apply):
Ways to use photos:
Clinic website
Social media (e.g., Facebook, Instagram)
Printed materials (e.g., brochures, posters, office displays)
Client education or presentations
Other
NO, I do not grant permission to use my submitted photos.
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PARENT/GUARDIAN AGREEMENT
I confirm that:
I am the parent/legal guardian of the child in the submitted photos and have the authority to grant this consent.
I own or have the right to share these images.
I understand that my child's identity will be protected and their face will not appear in any publication.
I understand that no financial compensation will be provided for the use of the images.
I may revoke this consent in writing at any time, though it will not apply to materials already created, distributed, and/or published.
Child's Full Name:
Parent/Guardian Name:
Relationship to Child:
Date Submitted:
-
Month
-
Day
Year
Date
Signature of Parent/Guardian:
Contact Information:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
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