I authorize Children’s Service Society of Wisconsin (also known as Children’s Wisconsin Community Services) to record by any means (still photographs, videotape, digital imaging, etc.) the individual(s) listed below.
The recordings may be used to market our programs, as educational tools or for other purposes.
The recordings may be shared via social media (Facebook, etc.), Children’s Wisconsin’s website, advertisements (television, radio, internet) or by other means.
This authorization is valid indefinitely unless revoked in writing. I understand that I have the right to revoke this authorization at any time. I can do so by submitting my revocation in writing to Laura Goba at firstname.lastname@example.org.
I understand that my revocation will not apply to recordings that have already been used pursuant to this authorization.
I understand that this authorization is voluntary. Children’s Wisconsin Community Services will not condition my or my child’s treatment, payment and enrollment in a health plan or eligibility for health care benefits based on my decision to sign this authorization.
I agree that all recordings become the property of Children’s Wisconsin Community Services. I hereby release Children’s Wisconsin, its employees, affiliates, or agents from any and all claims and demands arising out of, or in connection with, the use of these recordings pursuant to this agreement, including, but not limited to, any claims of defamation or invasion of privacy.
I have had an opportunity to review this form, ask questions and I authorize the recording and use of me and/or me child(ren).