Photo / Video Consent Form

Image / Video Upload

Upload Files

Please include brief descriptions of image(s) and/or video(s).

Name (Person 1)*

First NameLast Name

E-mail (Person 1)*

Name (Person 2)

First NameLast Name

Email (Person 2)

example@example.com

Name (Person 3)

First NameLast Name

Email (Person 3)

example@example.com

Please note that all adults depicted in the image(s), over the age of 18, will need to provide consent as indicated below.

Please indicate whether or not you give permission for Spence-Chapin Services to Families and Children (“Spence-Chapin”) to use any and all photographs and/or video clips (live or recorded) of yourselves and/or your child(ren) provided to Spence-Chapin by you personally or through public media or social media and/or any and all photographs and/or video clips (live or recorded) of yourselves and/or your child(ren) taken by Spence-Chapin, its employees, agents, or representatives by checking the appropriate space below.

Please select all that apply*

I consent to the use and distribution of my/our likeness by Spence-Chapin.I consent to the use and distribution of my/our child(ren)’s likeness by Spence-Chapin.I do not consent to the use and/or distribution of my likeness by Spence-Chapin.I do not consent to the use and/or distribution of my/our child(ren)’s likeness by Spence-Chapin.

I/we understand and acknowledge that I/we may be identified as Spence-Chapin birth parents, pre/adoptive parents, pre/adoptive families, volunteers or clients in the text/audio accompanying the photograph(s) and/or video(s). Please indicate whether you authorize Spence-Chapin to use your name(s) in conjunction with the above use(s) by checking the appropriate space below.

Select appropriate box below.*

Spence-Chapin is authorized to use my/our name(s).Spence-Chapin is authorized to "tag" me/us on social media and my/our social media handles are: Facebook:_______________ Twitter:_______________ Instagram:_______________Spence Chapin is not authorized to use my/our name(s) in any publication(s) or media source.

I/We hereby waive any right to inspect or approve the final product, as well as any ownership interest in the final product and/or any claims to compensation for use of the photograph(s) and/or video(s).

I/We understand that I/we may withdraw this consent at any time by submitting to Spence-Chapin my/our written request to withdraw. However, any such withdraw request will not apply to work already in progress.

I/we acknowledge that I/we have read this Agreement in full and that I/we understand and accept the terms of the Agreement in its entirety. I/we understand that a facsimile, scanned, or other electronic signature(s) shall have the same force and effect as an original.

By checking this box and typing my full name into the space below, I acknowledge this constitutes my original signature, authorizing my consent.

Signature (Person 1)*

First NameLast Name

Date (Person 1)*

MonthDayYear

Signature (Person 2)

First NameLast Name

Date (Person 2)

MonthDayYear

Signature (Person 3)

First NameLast Name

Date (Person 3)

MonthDayYear