FCDHHC - Media Permission Form

Media Permission Form
The Family Centre for Deaf and Hard of Hearing Children uses media for educational and promotional purposes. Photos, audio and video recordings may be used for education and training for your family, other families and professionals, as well as general publicity, including social media.

I give permission for the Family Centre for Deaf and Hard of Hearing Children to use the following media of my family without compensation for the following purposes (please select all that apply):
Photographs:
Audio recordings:
Video recordings:
Would you like to be contacted prior to the use of media of your family (as indicated above)?*
This agreement will be reviewed annually.

By signing below, I confirm that I agree to the terms laid out above.
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you wish to be sent a digital copy of this form, please enter your email address here.
example@example.com
Name of parent/legal guardian filling out this form

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: