Social Media Consent/Release Form
Name of person served by Siffrin:
*
First Name
Last Name
Name of individual, parent, or guardian:
*
First Name
Last Name
Relationship to Individual:
*
Self
Parent
Guardian
Please choose one regarding the use of images and/or videos:
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I authorize Siffrin to use my photo and/or information related to the services I receive for Social Media use. I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, and Siffrin’s social media accounts. My consent is freely given as a public service to Siffrin, without expecting payment. I understand that I can revoke this release any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease. I understand that printed materials and cached web pages can exist after I revoke this release. Consent is valid for one year from the date of signature.
No, I am refusing to grant consent at this time.
I prefer that:
*
No name be used
My first name only be used
My full name can be used
Signature of Individual, Parent or Guardian,
*
Date
*
Witness Signature
Witness Name
Date
Submit to Siffrin
Should be Empty: