Photo and Video Consent Form

Pathways Pediatric Services seeks your permission to use photographs and video content featuring your child's big beautiful smile for the purposes of in-house training and external marketing/communications. Please read and complete the following release form.

I,

Parent or guardian's first and last name:

, hereby grant Pathways Pediatric Services (hereinafter referred to as "the Organization"), and its employees, contractors, and agents, permission to use photographs and video recordings of my child,

Child's first name and last name:

, born on

Child's Birth Date

for the following purposes:

In-House Training: The Organization may use these images and recordings for internal training and educational purposes, including but not limited to, staff training, professional development, and educational materials.
External Marketing/Communications: The Organization may use these images and recordings for external marketing and communications purposes, which may include, but are not limited to, the Organization's website, social media, brochures, newsletters, and other promotional materials.

Yes, I understand and agree to the following terms and conditions:

1. The Organization may use these images and recordings without any compensation to me, my child, or any other party involved.

2. The Organization may edit, reproduce, publish, and distribute these images and recordings at its discretion.
I release and discharge the Organization, its employees, contractors, and agents, from any and all claims, demands, actions, or liabilities arising out of the use of these images and recordings.

3. I release and discharge the Organization, its employees, contractors, and agents, from any and all claims, demands, actions, or liabilities arising out of the use of these images and recordings.

4. I acknowledge that I have the legal authority to grant this permission as the parent or legal guardian of

Child's first name and last name

5. This release is valid indefinitely and may be revoked only in writing by me, the parent or legal guardian.

6. The Organization will make all reasonable efforts to ensure that my child's images and recordings are used in a respectful and appropriate manner.

By checking this button, I indicate my understanding and acceptance of the terms and conditions outlined in this Model Release Form.

Today's Date

Parent/Guardian's Full Name

Address

Email Address

Phone Number

Thank you for your cooperation in helping Pathways Pediatric Services fulfill its training and marketing, communications and most important of all, educational objectives.

Photo and Video Release Form